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PRACTICAL  ORTHODONTIA 


PRACTICAL 


ORTHODONTI 


JL 


BY 

MARTIN  DEWEY,  D.D.S.,  M.D. 

FORMERLY    HEAD    OF    THE    DEPARTMENT    AXI>    ASSOCIATE    PROFESSOR    OF    ORTHODONTIA    IN 

UNIVERSITY     OF    [OVA;     FORMERLY     PROFESSOR    OF    DENTAL    AXA'I'OMY    AND 

ORTHODONTIA,   KANSAS   CITY    DENTAL  COLLEGE  J    PRESIDENT  OF 

THE    DEWEY    SCHOOL    OF    ORTHODONTIA 


FOURTH  REVISED  EDITION 


ST.  LOUIS 
C.  V.  MOSBY  COMPANY 

1919 


RV  ' : 


Copyright,  1916,  1017,  1919,  By  C.  V.  Mosby  Company 


Press    of 

C.    V.    Mosby    Company 

St.   Louis 


TO 

EDWARD  II.  ANGLE,  M.D.,  D.D.S. 

IN    RECOGNITION    OF  THE    [NSPIRATION    AND    HELP 

DERIVED    FROM    1JI.M 

IX    MY    EARLY    DAYS   IN    ORTHODONTIA 

THIS  VOLUME  IS  RESPECTFULLY   DEDICATED 

I5Y   THE  AUTHOR 


PREFACE  TO  FOURTH  EDITION 

In  the  third  edition  of  this  work,  published  in  1917,  considerable 
space  was  devoted  to  the  use  of  the  lingual  arch,  and  attention  was  di- 
rected to  the  possibilities  of  the  high  labial  arch  with  finger  spring  ex- 
tension. During  the  two  years  that  have  elapsed  since  that  time  the 
author  has  continually  used  in  his  practice  different  forms  of  lingual 
arches  and  the  high  labial  arch  with  finger  spring  extension,  as  well  as 
experimented  with  other  styles  of  appliances  in  clinical  work.  As  a 
result  of  observations,  both  in  his  own  practice  and  in  the  practice  of 
others,  he  has  reached  the  conclusion  that  the  use  of  regulating  appli- 
ances will  necessarily  be  governed  by  the  proficiency  attained  by  certain 
men  in  the  manipulation  of  certain  types  of  appliances.  The  universal 
regulating  appliance  will  never  be  possihle  until  all  men  have  attained 
the  same  degree  of  proficiency  in  the  treatment  of  irregularities,  the 
same  mechanical  and  technical  skill,  and  until  all  have  mastered  the 
same  mechanical  principles  concerned  in  the  construction  and  manipula- 
tion of  appliances  and  in  the  production  of  anchorage.  At  the  present 
lime  an  appliance  that  is  successful  and  ideal  in  the  hands  of  one  may  not 
be  so  in  the  hands  of  another.  It  has  been  thoroughly  demonstrated 
from  observation  in  the  practice  of  a  number  of  orthodontists  and  in  post- 
graduate and  college  work  that  the  fundamental  necessities  in  the  prac- 
tice of  orthodontia  are  made  up  of  a  study  of  certain  basic  mechanical 
principles,  and  if  these  principles  are  mastered,  regulating  appliances 
will  necessarily  evolve  in  the  hands  of  each  man  along  these  basic  lines. 

The  author  believes  that  for  the  orthodontist  who  has  mastered 
mechanical  principles  and  is  skilled  in  orthodontic  technic,  the  lingual 
arch  used  with  the  wire-stretching  pliers  offers  many  advantages  and 
possibilities.  However,  the  use  of  such  an  appliance  in  the  hands  of  an 
inexperienced  operator  would  not  be  satisfactory  and  probably  would  be 
detrimental  to  the  patient.  To  those  inexperienced  in  the  use  of  sol- 
dered lingual  arches,  the  removable  lingual  arch  offers  a  safer  technic, 
and  the  author  would  recommend  its  use  until  the  practitioner  has  mas- 
tered the  principles  of  the  wire-stretching  pliers,  and  then  he  can  use 
the  pinched  or  soldered  lingual  arch.  An  appliance  that  is  easier  to 
manipulate,  and  one  that  is  inconspicuous  and  offers  advantages  in  many 
cases,  is  the  high  labial  arch  with  finger  spring  extensions  and  recurved 
extensions,  as  advocated  by  Dr.  Lloyd  S.  Lourie.  In  the  use  of  the  high 
labial  arch  or  the  removable  lingual  arch  a  fundamental  principle  that 

7 


8  PREFACE 

must  be  observed  is  that  of  anchorage.  The  author  is  convinced  that 
many  of  the  basic  principles  in  any  style  of  regulating  appliance  will  be 
found  in  the  study  of  anchorage.  This  has  also  been  emphasized  by  Dr. 
Pullen. 

The  use  of  the  lingual  arches  and  the  high  labial  arch  requires  a  more 
perfected  technique  than  does  the  use  of  the  labial  alignment  wire  with 
ligatures,  therefore,  to  one  who  has  treated  few  cases,  this  type  of  ap- 
pliance is  recommended,  as  less  trouble  will  be  experienced  and  better 
results  accomplished.  To  the  operator  inexperienced  in  the  use  of  the 
lingual  arch,  the  Jackson  removable  appliance  is  to  be  recommended. 
Its  simplicity  of  adaptation  and  its  conservation  of  anchorage  causes 
this  to  be  an  ideal  appliance  with  which  to  begin  the  use  of  the  lingual 
devices.  Realizing  that  no  one  appliance  is  universal,  the  author  has 
endeavored  to  describe  the  treatment  of  every  type  of  malocclusion  us- 
ing different  types  of  appliances. 

In  addition  to  those  who  contributed  to  the  third  edition  of  this  work, 
the  author  is  indebted  to  Dr.  Lloyd  S.  Lourie  for  illustrations  used  to 
elucidate  the  technique  of  the  lingual  appliance  and  the  high  labial  arch 
with  spring  extensions;  to  Dr.  John  V.  Mershon,  of  the  University  of 
Pennsylvania,  for  suggestions  in  the  use  of  the  removable  lingual  arch 
with  finger  springs;  and  to  Dr.  W.  W.  Martin,  of  the  University  of 
Iowa,  for  his  faithful  cooperation  in  working  out  in  clinical  practice 
some  of  the  mechanical  principles. 

An  effort  on  the  part  of  the  author  has  been  made  to  limit  the  book 
to  such  principles  as  have  proved  of  value  in  practice,  and  it  is  hoped 
that  this  edition  will  render  as  great  a  service  to  orthodontists,  students, 
and  teachers  as  its  predecessors  have  done. 

M.  D. 


Chicago,  111. 


PREFACE  TO  THIRD  EDITION 


Since  the  first  edition  of  this  work  was  published  in  1914,  ortho- 
dontia has  made  many  advances,  and  the  author  has  endeavored  to 
bring  this  third  edition  up  to  date.  While  the  arrangement  of  the 
text  remains  practically  the  same  as  in  the  first  edition,  several  new 
chapters  and  about  four  hundred  new  illustrations  have  been  added. 
At  its  seventeenth  annual  meeting  the  American  Society  of  Orthodon- 
tists adopted  a  new  terminology,  which  differs  from  that  used  in  the 
first  edition  of  this  work.  The  new  terminology  has  been  used  through- 
out this  edition  in  conjunction  with  the  old  in  order  to  enable  the 
student  and  the  general  practitioner  to  become  familiar  with  the  new. 


PBEFACl  J 

Many   notable  advances  have   been   made  in   regulating  appliances 

with  the  result  that  the  old  expansion  arch  still  remains  the  standard. 
However,  in  place  of  the  Labial  alignmenl  wire,  Dr.  Lloyd  S.  Lourie 
and  Dr.  John  V.  Mershon  have  introduced  the  lingual  alignmenl  wire, 
which  makes  a  very  inconspicuous  appliance  and  deserves  a  place 
in  orthodontia.  .More  and  more  attention  is  being  given  to  the  cor- 
rection of  the  teeth  by  the  use  of  delicate  appliances.  The  bodily 
movement  of  the  teeth  is  also  receiving  more  consideration  than  for- 
merly. It  has  been  shown  thai  such  movement  can  he  accomplished 
with  very  delicate  appliances:  all  that  is  necessary  being  an  appliance 
that  gives  a  two-point  contact,  ami  if  the  pressure  is  constant  and  in 
the  righl  direction,  the  movement  will  l»e  accomplished.  The  author 
has  endeavored  to  show  only  such  appliances  as  have  proved  valuable, 
or  that  have  some  feature  recommending  their  use  above  all  other 
appliances  in  particular  inims. 

The  author  is  indebted  to  Dr.  Oren  A.  Oliver,  Professor  of  Ortho- 
dontia in  the  Dental  Departmenl  of  the  Vanderbilt  University,  for  a 
well  illustrated  description  of  the  technique  of  facial  cast  construction. 
The  chapter  on  facial  deformities  will  he  found  of  value,  and  the 
author  desires  to  express  his  gratitude  to  Dr.  B.  E.  Lischer,  Professor 
of  Orthodontics  in  the  Dental  Departmenl  of  Washington  University, 
for  the  many  beautiful  illustrations  contained  in  this  chapter.  For 
the  technique  for  duplication  of  models  and  the  illustrations  thereof. 
the  author  wishes  to  thank  Dr.  .1.  A.  < '.  Hoggan,  Professor  of  Ortho- 
dontia. School  of  Dentistry,  Medical  College  of  Virginia. 

The  science  of  orthodontia  is  indebted  to  Dr.  Lourie  ami  Dr.  Mershon 
for  the  technique  of  the  Lingual  arch,  which,  in  the  author's  opinion,  is 
one  of  the  greatest  advances  made  in  recent  years.  The  chapter  on 
the  use  of  the  x-ray  in  orthodontia  has  been  written  by  Dr.  James 
David  McCoy,  professor  of  Orthodontia  and  Radiography,  College  of 
Dentistry,  University  of  Southern  California.  Dr.  Joseph  D.  Eby.  of 
Atlanta.  Ga.,  has  furnished  much  of  the  material  and  illustrations 
for  the  chapter  on  the  removable  regulating  appliance.  The  author 
also  wishes  to  express  his  indebtedness  to  Dr.  A.  E.  Suggett  for  a 
description  of  the  use  of  the  .0225  alignment  wire.  The  chapter  on 
malocclusion  and  nasal  deformities  is  also  a  valuable  addition  to  the 
work.  Illustrations  have  been  secured  from  numerous  sources,  to  all 
of  which  recognition  has  been  given. 

This  book  is  an  endeavor  to  furnish  a  text  of  practical  value  to 
orthodontists,  to  students  in  dental  colleges,  and  to  teachers,  and  it  is 
hoped  that  to  these  it  will  be  of  service. 

M.  D. 


10  PREFACE 

PEEFACE  TO  FIRST  EDITION 

Believing  thai  there  should  be  a  book  more  suited  to  the  needs  of 
the  studenl  of  orthodontia  than  any  which  we  now  have,  the  author 
has  attempted  to  include  in  this  volume  certain  principles  which  he 
lias  found  to  partially  fulfill,  at  least,  the  needs  of  his  students. 

Occlusion  being  the  basis  of  orthodontia,  much  space  lias  been  de- 
voted  to  the  different  forces  of  occlusion,  and  there  has  also  been 
added  a  table  giving  the  occlusion  of  each  of  the  inclined  planes  of  the 
teeth. 

Classification  lias  been  based  on  the  mesiO-distal  relation  of  the 
teeth  and  since  Angle's  plan  of  nomenclature  appears  to  be  the  one 
most  universally  used,  it  has  been  adhered  to.  Under  classification  cer- 
tain types  have  been  included  which  are  so  different  as  to  require  a 
different  technique  in  treatment. 

Causes  of  malocclusion  have  been  taken  up  under  different  headings 
and  described. 

Under  appliances,  the  author  has  confined  his  discussion  to  those 
which  have  proved  their  worth  and  which  he  believes  will  be  success- 
ful in  the  greatest  number  of  cases.  The  principles  of  retention  have 
been  carefully  explained,  for  undoubtedly  much  unnecessary  trouble 
has  resulted  in  the  past  by  not  taking  into  consideration  the  principles 
involved. 

It  has  been  the  aim  of  the  author  to  confine  his  discussion  to  the 
practical  side  of  the  question  rather  than  to  the  historical  features. 
Very  little  has  been  said  about  art  as  related  to  orthodontia.  Neither 
has  he  dwelt  upon  the  histological  side  of  tooth  movement  or  the  de- 
velopment of  bone,  as  these  subjects  should  be  taught  by  the  chair 
of  histology.  Mention  has  been  made  of  only  such  appliances  as 
would  be  in  keeping  with  physiological  tooth  movement  and  bone 
growth.  The  author  has  purposely  omitted  any  reference  to  the  dis- 
puted question  of  opening  the  suture  as  an  aid  to  orthodontic  treat- 
ment. These  questions  are  still  unsettled  and  therefore  should  not 
be  incorporated  in  a  work  of  this  kind  to  confuse  the  student.  Since  a 
great  many  methods  pertaining  to  orthodontia  have  been  advanced 
by  different  authorities  in  the  past,  and  as  priority  is  often  a  matter 
of  dispute,  the  author  has  not  attempted  to  give  credit  for  everything ; 
neither  does  he  claim  originality  for  anything  contained  herein.  While 
he  has  done  certain  things  and  advanced  certain  theories  which  were 
new  to  him  at  one  time,  others  have  done  the  same  twenty  years  ago. 


PREFACE  11 

Lastly,  this  book  is  not  supposed  to  be  the  final  solution  of  all  things 
pertaining  to  orthodontia,  but  is  intended  for  those  interested  in  the 
subject  who  may  be  helped  as  a  result  of  some  of  the  author's  experi- 
ence gained  during  a  period  of  twelve  years  as  a  teacher  of  ortho- 
dontia. 

M.  D. 


CONTENTS 

Chapter  I 

OCCLUSION 

Occlusion  of  the  Teeth — Table  Showing  Occlusion  of  Inclined  Planes 17 

Chapter  II 

FORCES  OF  OCCLUSION 

Definition — Line   of   Occlusion — Classifieati f    Forces    of   Occlusion-  Normal 

Cell  Metabolism— ^Muscular  Pressure-^Force  of  the  Inclined  Plane— -Nor- 
mal Approximal  Contact -— llarmony  in  the  Size  of  the  Arches — Normal  At- 
mospheric   Pressure 28 

( 'ii  \pti:r  III 

MALOCCLUSION 

Positions  of  Malocclusion,  or  Malpositions  of  the  Teeth  Classification  of  Mal- 
occlusion, or  Mali-elation  of  the  Arches — Neutroclusion,  or  Class  I — Neutro- 
clusion, or  Class  I,  Mutilated  Cases — Types  of  Neutroclusion,  or  Class  I — 
Neutroclusion  With  Bunched  Anterior  Teeth,  or  Class  I,  Type  1 — Neutro- 
clusion With  Labioversion  of  Upper  Incisors,  or  Class  I,  Type  2 — Neutroclu- 
sion With  Linguoversion  of  Upper  Anterior  Teeth,  or  Class  1,  Type  3 — - 
Distoelusion,  or  Class  II — Distoelusion  With  Labioversion  of  Maxillary  In- 
cisors, or  Class  II,  Division  1 — Distoelusion  With  Linguoversion  of  Upper 
Anterior  Teeth,  or  Class  II,  Division  2 — Mesioclusion,  or  Class  III — Class 
III,  Type  1— Class  III,  Type  12— Class  III,  Type  3— Unilateral  Mesio- 
clusion, or  Class  III,  Subdivision — Unilateral  Mesioclusion  and  Distoelu- 
sion— Malformation  of  the  Jaws  and  Their  Processes,  and  Abnormal  Rela- 
tion of  the  Mandible  to  the  Maxillae — Malocclusion  ami  Facial  Deformities..     42 

Chapter  IV 

ETIOLOGY  OF  MALOCCLUSION 

General  or  Constitutional  Causes  Local  Causes — Inherited,  Congenital  and  Ac- 
quired Causes — Inherited  Causes — Congenital  Causes — Acquired  Causes — - 
Early  Loss  of  the  Deciduous  Teeth — Tardy  Eruption  of  the  Permanent 
Teeth — Early  Loss  of  the  Permanent  Teeth — The  Loss  of  the  Mesio-Distal 
Diameter  of  the  Teeth — Improper  Restoration — Mouth-breathing — Enlarged 
Tonsils— Habits— Sore    Teeth 117 

13 


14  CONTENTS 

Chapter  V 

R  EGULATING  AIM  'LI  ANCES 

Principles  of  Regulating  Appliances — Requirements  of  Regulating  Appliances — 
Efficiency  Durability  Cleanliness  and  Antisepsis — Simplicity — Inconspic- 
uousness — Fixed  and  Removable  Appliances — Fixed  Appliances — Remov- 
able Appliances — Technique  for  Making  Regulating  Appliances — Bands — 
Composition  of  Appliances — Gold — Band  Technique — Direct  Band  Tech- 
nique— Indirect  Band  Technique — Soldering  Technique — Adjusting  Clamp 
Hands — Ligatures — Rubber  Ligatures — Wire  Ligatures — Fixed  Regulating 
Appliances — Alignment  Wires  or  Expansion  Arches — Attachments  for  the 
Alignment  Wire  of  Expansion  Arch — Application  of  the  Labial  Alignment 
Wire  or  Expansion  Arch — Loop  Labial  Alignment  Wires — Lingual  Arches, 
or  Alignment  Wires — Technique  of  Wire  Stretching — Appliances  for  the 
Bodily  Movement  of  Teeth — The  Lingual  Arch  Used  in  Connection  With 
the  Labial  Arch 157 

Chapter  VI 

REMOVABLE  REGULATING  APPLIANCES 

Definition — Early  Types  of  Appliances — Coffin's  Split-spring  Plate — Jackson 
System  of  Removable  Appliances — Instruments — Materials — Models — Full 
and  Partial  Spring  Clasps — Base  or  Body  Wires — Finger  Springs — Lower 
Jackson  Appliance — Anchorage — Valuable  Features  of  Removable  Appli- 
ances     253 

Chapter  VII 
ANCHORAGE 
Intra  maxillary  Anchorag< — I  otermaxillary    Anchorage     Extramaxillary   Anchor- 


280 


Chapter  VIII 
RETENTION  OF  TEETH 

Fon-cs  of  Retention — Mechanical  Forces — Passive  Mechanical  Forces — Active 
Mechanical  Force — intramaxillary  Retention — Intermaxillary  Retention — 
Extramaxillary  Retention — Natural  Forces — Force  of  the  Inclined  I'lam — 
Harmony  in  the  Size  of  the  Arches — Normal  Muscular  Pressure — Normal 
Approximal  Contact — Normal  Cell  Metabolism — Normal  Atmospheric  Pres- 
sure— Summary  of  Forces  of  Retention — Mechanical  Forces  of  Retention — 
Simple  Passive  Intramaxillary  Retention — Simple  Compound  Intramaxillary 
Retention — Stationary  Intramaxillary  Retention — Reciprocal  Intramaxillary 
Retention — Compound  Reciprocal  Retention — Intermaxillary  Retention — ■ 
Active  Primary  Intermaxillary  Retention — Reciprocal  Intermaxillary  Re- 
tention— Passive  Reciprocal  Simple  Intermaxillary  Retention — Plane  and 
Spur  Retention — Passive  Reciprocal  Stationary  Intermaxillary  Retention — 
Active  Primary  Reciprocal  Intermaxillary  Retention — Active  Compound 
Reciprocal    [ntermaxillary    Retention — Extramaxillary    Retention 299 


CONTENTS  1 5 

Chapter  IX 

IMPRESSIONS  AND  MODELS. 

Preliminary  Consideration  of  Cases — Taking  the  Impression — Varnishing  the  Im- 
pression— Pouring  the  Model — Separating  the  Model — Trimming  the 
Model — Modeling  Compound  to  .Study  Models — Duplicating  Orthodontia 
Models — Photographs — Facial    Casts 318 

Chapter  X 

USE  OF  THE  X-EAY  IN  ORTHODONTIA 

The  Question  of   Technique— Seating  the   Patient — Indications    for  the  Use  of 

the  X-ray  by  the  Orthodontist 359 

Ch  '.pt!  b   X  I 

TREATMENT   OF  ('ASKS 

Neutroclusion,  or  Class  I — Mutilated  Cases  of  class  I — Bilateral  Distoclusion 
With  Labioversion,  or  Class  II,  Division  1 — Unilateral  Distoclusion  With 
Protruding  Anterior  Teeth,  or  Class  II,  Division  1,  Subdivision — Bilateral 
Distoclusion  With  Retruding  Anterior  Teeth,  or  Class  II,  Division  2 — Uni- 
lateral Distoclusion  With  Retruding  Teeth,  or  Class  II,  Division  2,  Suit- 
division — Bilateral  Mesioclusion,  or  Class  III — Unilateral  Mesioclusion,  or 
Class   III,   Subdivision 374 

Chapter  XII 

MALOCCLUSION   A\l>  NASAL   DEFORMITIES 

Malocclusion  and  Xasal  Deformities 499 


PRACTICAL  ORTHODONTIA 


CHAPTER  1 
OCCLUSION 

Orthodontia  is  the  science  that  lias  for  its  object  the  correction  of 
malocclusion  of  the  teeth. 

Malocclusion  is  a  deviation  from  the  normal  to  such  an  extent  as  to 
interfere  with  the  functions  of  the  teeth. 

Normal  occlusion  is  the  relation  of  the  inclined  planes  of  the  teeth  as 
intended   by   nature. 

Occlusion  is  the  relation  of  the  inclined  planes  of  the  teeth. 

As  orthodontia  is  the  science  that  deals  with  the  malocclusion  of 
the  teeth,  it  necessarily  follows  that  a  study  of  this  subject  includes 
a  thorough  understanding  of  the  teeth  as  arranged  by  nature  (Fig. 
1).  Each  one  of  the  teeth  has  a  definite  position  in  the  dental  arch, 
not  only  with  the  teeth  of  each  individual  arch,  but  also  with  those 
of  the  opposing  arch  (Fig.  2).  To  recognize  malocclusion  it  is  neces- 
sary that  we  be  familiar  with  normal  occlusion.  Not  only  has  each 
tooth  a  definite  and  positive  relation  with  a  tooth  of  the  opposite 
arch,  but  each  inclined  plane  of  each  cusp  has  a  certain  relation  with 
the  inclined  plane  of  some  other  cusp.  By  a  study  of  the  anatomy  of 
the  teeth,  we  find  each  cusp  to  be  made  up  and  bounded  by  marginal 
ridges  and  developmental  ridges  and  grooves.  These  ridges  and 
grooves  also  separate  the  cusps  into  definite  inclined  planes.  The  oc- 
clusal inclined  planes  of  the  teeth  are  named  from  the  surfaces  to- 
ward which  they  face,  and  their  names  are  derived  from  a  combina- 
tion of  the  four  terms,  mesial,  distal,  buccal,  and  lingual  (Fig.  3).  In 
studying  the  arrangement  of  the  teeth,  we  find  that  the  lower  teeth 
are  set  one  inclined  plane  in  advance  of  the  upper  teeth.  This  is 
made  possible  because  the  lower  central  incisor  is  narrower  than  the 
upper  central  incisor.  When  we  reach  the  upper  canine,  we  find  that 
the  upper  canine  occludes  with  the  lower  canine  and  a  portion  of 
the  lower  first  premolar.     Passing  from  the  buccal  to  the  lingual,  we 

17 


18 


PRACTICAL    ORTHODONTIA 


find  that  the  upper  teeth  are  one-half  of  a  cusp  to  the  buccal  of  the 
lower  teeth  (Fig.  4)  ;  that  is,  the  lingual  cusps  of  the  upper  molars 
and  premolars  occlude  between  the  buccal  and  lingual  cusps  of  the 


Fig.    1. — Normal   occlusion   of   teeth.      (Summa.) 

lower  molars  and  premolars  (Fig.  5).  The  buccal  cusps  of  the  lower 
molars  and  premolars  occlude  between  the  buccal  and  lingual  cusps 
of  the  upper  molars  and  premolars.  By  studying  Figs.  1,  2,  4  and  5 
some   idea   can   be   gained   of   their  arrangement.      Probably   a   much 


OCCLUSION 


19 


Fig.    2. — Normal    occlusion    (Aztec   skull).      (Ketcham.) 


20 


PRACTICAL    ORTHODONTIA 


better  idea  can  be  obtained  by  studying  the  diagram  shown  in  Fig.  G. 
It  becomes  apparent   that    the   inclined   planes  of   the  teeth  are  neces- 


BUCCAL 


LINGUAL 


1    II 


M.B.I nciines  MUndines  D.B.Inclines  Di.lnclines 

Fig    3.  —  Showing  occlusal   inclined   planes   of  the  cusps. 

sarily  arranged   diagonally  to  the   mesio-distal    relation   of  the  arches. 
They   are   named    mesio-buccal,    mesio-lingual,    disto-buecal   and   disto- 


Fig.   4. — Buccal   and  lingual   relation    of   molars. 


lingual.     A  point  to  be  remembered  in   studying  the  occlusion  of  the 
teeth  is  that  the  mesio-buccal  cusp  of  the  upper  first  molar  occludes 


OCCLUSION 


21 


Fig.   5. — Shows  relation  of  lingual  cusps  of  upper  molar  to  lower. 


Disto-Buccal  Mcsio-Buccdl  Disto-Linqual  Mcsio-LiMquoi 

Inclines  Inclines  Inclines  Inclines 

Fig.   6. — Shows  relation   of  cusps  and   inclined   planes.      Upper   cusps,   square;   lower   cusps,    round. 
Note  position  of  mesio-lingual  cusp   of  upper  molar  and   disto-buccal   cusp   of  lower. 


22 


PRACTICAL    ORTHODONTIA 


in  the  buccal  groove  of  the  lower  first  molar.  This  arrangement  is 
found  on  all  of  the  molar  teeth.  The  mesio-lingual  cusps  of  the  maxil- 
lary molars  occlude  in  the  central  fossa?  of  the  corresponding  mandibular 
molars.  The  mesio-lingual  cusp  of  the  maxillary  molar  is  surrounded 
by  the  four  cusps  of  the  corresponding  mandibular  molar.  The  disto- 
buccal  cusp  of  the  mandibular  molar  occludes  in  the  corresponding  cen- 
tral fossa  of  the  maxillary  molar,  which  makes  the  disto-buccal  cusps  of 


£2 

> 


■:•-''  o 


LINGUAL 


Fig.    7. — Maxillary    and    mandibular    molar,    showing    mesio-lingual    cusp    in    central    fossa    of 
mandibular   molar.      Initial    letters    of    cusps   and    inclines    used;    e.    g.,    M.B.I. — D.B.C.    refers    to 

mesio-buccal  incline  of  disto-buccal  cusp. 

the  mandibular  molars  surrounded  by  the  four  cusps  of  the  correspond- 
ing maxillary  molars.  However,  in  the  case  of  the  mandibular  first  mo- 
lar, which  has  a  disto-buccal  and  distal  cusp,  the  arrangement  is  a  little 
different;  but  ordinarily  we  consider  the  disto-buccal  and  distal  cusp  as 
one  cusp.  Another  point  to  remember  is  that  the  lingual  surfaces  of  the 
lingual  cusps  of  the  mandibular  molars  and  premolars  arc  also  without 
occlusion. 


OCCLUSION 


23 


The  occlusion  of  the  inclined  planes  of  the  maxillary  teeth  with  the 
mandibular  is  given  in  the  following  table.  The  left-hand  column  con- 
tains cusps  of  the  upper  teeth,  while  the  right-hand  column  refers  to  the 
lower  teeth.  By  reading  the  left-hand  column  first  we  are  given  the 
occlusion  of  the  maxillary  teeth  with  the  mandibular,  and  by  reading  the 
right-hand  column  first  we  are  given  the  occlusion  of  the  mandibular 
teeth  with  the  maxillary.  It  is  necessary  that  they  who  expect  to  treat 
malocclusion  must  know  the  relation  of  the  inclined  planes  of  each  cusp 
or  it  will  be  absolutely  impossible  to  diagnose  and  treat  correctly  maloc- 
clusion of  the  teeth. 


Table  Showing  Occlusion  of  Inclined  Planes 


MAXILLARY  TEETH 

The   occlusal   lingual   third   of  the 

maxillary  first   (central)   incisor. 


The  occlusal  lingual  third  of  the 
maxillary  second  (lateral)  inci- 
sor      

The  mesio-lingual  inclined  plane] 
of  the  maxillary  canine  (ens-  I 
pid) - J 

The  disto-lingual  inclined  plane] 
of  the  maxillary  canine  (cus-  I 
Pid) J 

The  mesio-lingual  inclined  plane] 
of  the  buccal  cusp  of  the  max-  I 
illary   first   premolar    (bieuspid)  I 

The  disto-lingual  inclined  plane] 
of  the  buccal  cusp  of  the  max-  ' 
illary   first   premolar    (bicuspid) 

The  mesio-buccal  inclined  plane] 
of  the  lingual  cusp  of  the  max-  I 
illary  first   premolar    (bicuspid)  | 

The  mesio-lingual  inclined  plane 
of  the  lingual  cusp  of  the  max- 
illary  first    premolar    (bicuspid) 


Occludes 
with 


occludes 

with 


occludes 
with 

occludes 
with 

occludes 

with 

occludes 
with 

occludes 

with 


occludes 
with 


MANDIBULAR    TEETH 

the  labial  occlusal  third  of  the 
mandibular  first  (central)  incisor 
and  the  mesio-labial  half  of  the 
occlusal  surface  of  the  mandibular 
second    (lateral)    incisor. 

the  disto-labial  occlusal  surface  of 
the  mandibular  second  (lateral) 
incisor  ami  the  mesio-labial  in- 
cline of  the  mandibular  canine 
I  cuspid  I. 

the  disto-buccal  inclined  plane  of 
the    mandibular    canine    (cuspid). 

the  mesio-buccal  inclined  plane 
of  the  buccal  cusp  of  the  mandib- 
ular first  premolar    (bicuspid). 

the  disto-buccal  inclined  plane  of 
the  buccal  cusp  of  the  mandibu- 
lar first  premolar    (bicuspid). 

the  mesio-buccal  inclined  plane  of 
the  buccal  cusp  of  the  mandibular 
[second  premolar    (bicuspid). 

fthe  disto-lingual  inclined  plane  of 
'  the  buccal  cusp  of  the  mandibular 
[  first  premolar  (bicuspid). 

the  disto-lingual  inclined  plane  of 
the  lingual  cusp  of  the  mandibu- 
lar first  premolar  (bicuspid). 
(This  cusp  is  often  underdevel- 
oped.) 


24 


PRACTICAL    ORTHODONTIA 


MAXILLARY   TEETH 

The  disto-buccal  inclined  plane] 
of  the  lingual  cusp  of  the  max-  I 
illary   first   premolar    (bicuspid) 

The  disto  lingual  inclined  plane  ] 
of  the  lingual  cusp  of  the  max-  I 
illary   first   premolar    (bicuspid) 

The  mesio-lingual  inclined  plane 
of  the  buccal  cusp  of  the  max- 
illary second  premolar  (bicus- 
pid)    

The  disto-lingual  inclined  plane 
of  the  buccal  cusp  of  the  max- 
illary second  premolar  (bicus- 
pid)    

The  mesio-buccal  inclined  plane 
of  the  lingual  cusp  of  the  max- 
illary second  premolar  (bicus- 
Pid)    

The    mesio-lingual    inclined    plan 
of  the  lingual  cusp  of  the  max- 
illary   second    premolar     (hicus- 
pid)    

The  disto-buccal  inclined  plane 
of  the  lingual  cusp  of  the  max- 
illary second  premolar  (bicus- 
P^)     

The  disto-lingual  inclined  plane  of] 
the  lingual  cusp  of  the  maxil-  I 
lary  second  premolar   (bicuspid) 

The  mesio-lingual  inclined  plane  l 
of  the  mesio-buccal  cusp  of  the  I 
maxillary    first    molar     

The  disto-lingual  inclined  plane  | 
of  the  mesio-buccal  cusp  of  the  [ 
maxillary    first    molar    

The  mesio-buccal  inclined  plane  of  | 
the  mesio-lingual  cusp  of  the  I 
maxillary    first    molar    

The  mesio-lingual  inclined  plane  ] 
of  the  mesio-lingual  cusp  of  the  l 
maxillary    first    molar     

The  disto-buccal  inclined  plane  ] 
of  the  mesio-lingual  cusp  of  the  1 
maxillary    first    molar    


occludes 
with 

occludes 
with 


occludes 
with 


occludes 
with 


occludes 
with 


occludes 
with 


occludes 

with 


occludes 
with 

occludes 
with 

occludes 
with 

occludes 
with 

occludes 
with 

occludes 
with 


MANDIBULAR    TEETH 

I  the  mesio-lingual  inclined  plane  of 
the  buccal  cusp  of  the  mandibular 
second    premolar    (bicuspid). 

(  the  mesio-buccal  inclined  plane  of 
the  lingual  cusp  of  the  mandibu- 
lar  second  premolar    (bicuspid). 

the  disto-buccal  inclined  plane  of 
the  buccal  cusp  of  the  mandibular 
second    premolar    (bicuspid). 


the  mesio-buccal  inclined  plane  of 
the  mesio-buccal  cusp  of  the  man- 
dibular first   molar. 


the  disto-lingual  inclined  plane  of 
the  buccal  cusp  of  the  mandibular 
second   premolar    (bicuspid). 

tic  disto-buccal  inclined  plane  of 
the  lingual  cusp  of  the  mandibular 
second   premolar    (bicuspid). 

the  mesio-lingual  inclined  plane 
of  the  mesio-buccal  cusp  of  the 
mandibular    first    molar. 

the  mesio-buccal  inclined  plane  of 
the  mesio-lingual  cusp  of  the  man- 
dibular first  molar. 

f|the  disto-buccal  inclined  plane  of 
the  mesio-buccal  cusp  of  the  man- 
dibular first  molar. 

the  mesio-buccal  inclined  plane  of 
the  disto-buccal  cusp  of  the  man- 
dibular first  molar. 

the  disto-lingual  inclined  plane  of 
,  the  mesio-buccal  cusp  of  the  man- 
dibular   first    molar. 

|  the   disto-buccal   inclined   plane   of 
J  the  mesio-lingual  cusp  of  the  man- 
dibular first  molar. 

f  the  mesio-lingual  inclined  plane 
of  the  disto-buccal  cusp  of  the 
mandibular  first  molar. 


()('(   1,1   SKIN 


25 


MAXILLARY  TEETH 

The  disto-lingual  inclined  plane 
of  the  mesio-lingual  cusp  of  the 
maxillary    first   molar 

The  mesio-lingual  inclined  plane 
of  the  disto-buccal  cusp  of  the 
maxillary    first    molar     

The  disto-lingual  inclined  plane 
of  the  disto-lmccal  cusp  of  the 
maxillary    first    molar     

The  mesio  buccal  inclined  plane 
of  the  disto-lingual  eusp  of  the 
maxillary    first    molar     

The  mesio-lingual  inclined  plane 
of  the  disto-lingual  cusp  of  the 
maxillary    first    molar     

The  disto-lmccal  inclined  plane 
of  the  disto-lingual  cusp  of  the 
maxillary    first    molar     

The  disto-lingual  inclined  plane 
of  the  disto-lingual  cusp  of  the 
maxillary    first    molar     

The  mesio-lingual  inclined  plane 
of  the  mesio-buccal  cusp  of  the 
maxillary    secoud    molar    

The  disto-lingual  inclined  plane 
of  the  mesio-buccal  cusp  of  the 
maxillary    second    molar    

The  mesio-buceal  inclined  plane 
of  the  mesio-lingual  cusp  of  the 
maxillary    second    molar    

The  mesio-lingual  iucliued  plane 
of  the  mesio-lingual  cusp  of  the 
maxillary    second    molar     

The  disto-buccal  inclined  plane 
of  the  mesio-lingual  cusp  of  the 
maxillary   second  molar 

The  disto-lingual  inclined  plane 
of  the  mesio-lingual  cusp  of  the 
maxillary   second  molar 


occludes 
with 


occludes 

with 


occludes 
with 


occludes 

with 


occludes 
with 


occludes 
with 


occludes 

with 


rclude 
with 


occludes 
with 


occludes 
with 


occludes 

with 


occludes 
with 


occludes 

with 


MANDIBULAR   TEETH 

the  mesio-buccal  inclined  plane 
of  the  disto-lingual  cusp  of  the 
mandibular  first  molar. 

the  disto-buccal  inclined  plain'  of 
the  disto-buccal  cusp  of  the  man- 
dibular first  molar. 

the  mesio-buccal  inclined  plane  of 
the  mesio-buccal  cusp  of  the  man- 
dibular   second    molar. 

the  disto-lingual  inclined  plane  of 
the  disto-buccal  cusp  of  the  man- 
dibular first   molar. 

the  distil  buccal  inclined  plane  of 
the  disto-lingual  cusp  of  the  man- 
dibular  first   molar. 

the  mesio  lingual  inclined  plane 
of  the  mesio-buccal  cusp  of  the 
mandibular    second   molar. 

the  mesio-buccal  inclined  plane  of 
tlic  mesio-lingual  cusp  of  the  man- 
dibular second  molar. 

the  distu  buccal  inclined  plane  of 
the  mesio-buccal  cusp  of  the  man- 
dibular   second    molar. 

the  mesio-buccal  inclined  plane  of 
the  disto -buccal  cusp  of  the  man- 
dibular   second    molar. 

thi'  disto  lingual  inclined  plane 
of  the  mesio-buccal  cusp  of  the 
mandibular    second    molar. 

the  disto-buccal  inclined  plane  of 
the  mesio-lingual  cusp  of  the  man- 
dil  alar  second   molar. 

the  mesio-lingual  inclined  plane 
of  the  disto-buccal  cusp  of  the 
mandibular    second    molar. 

the  mesio-buccal  inclined  plane 
of  the  disto-lingual  cusp  of  the 
mandibular  second  molar. 


26 


PRACTICAL    ORTHODONTIA 


MAXILLARY  TEETH 

The  mesio-lingual  inclined  plane 
of  the  disto-buecal  cusp  of  the 
maxillary    second   molar    

The  disto-lingual  inclined  plane 
of  the  disto-bueeal  cusp  of  the 
maxillary    second    molar    

The  mesio-buccal  inclined  plane 
of  the  disto-lingual  cusp  of  the 
maxillary    second    molar    

The  mesio-lingual  inclined  plane 
of  the  distodingual  cusp  of  the 
maxillary    second    molar    

The  disto-bueeal  inclined  plane 
of  the  disto-lingual  cusp  of  the 
maxillary    second    molar    

The  disto-lingual  inclined  plane 
of  the  disto-lingual  cusp  of  the 
maxillary    second    molar    

The  mesio-lingual  inclined  plane 
of  the  mesio-buccal  cusp  of  the 
maxillary   third   molar    

The  disto-lingual  inclined  plane 
of  the  mesio-buccal  cusp  of  the 
maxillary   third  molar    

The    mesio-buccal     inclined     plane  i 
of  the  mesio-lingual  cusp  of  the 
maxillary  third  molar    

The  mesio-lingual  inclined  plane  | 
of  the  mesio-lingual  cusp  of  the  . 
maxillary   third   molar    

The     disto-buecal     inclined     plane 

of  the  mesio-lingual  cusp  of  the 
maxillary    third   molar    

The  disto-lingual  inclined  plane 
of  the  mesio-lingual  cusp  of  the 
maxillary   third  molar    

The  mesio-lingual  inclined  plane 
of  the  disto-buecal  cusp  of  the 
maxillary  third  molar    


occludes 

with 


occludes 

with 

occludes 
with 


occludes 

with 


occludes 

with 


occludes 

with 


occludes 

with 


occludes 

with 


occludes 

witli 


occludes 

with 


occludes 
with 

occludes 
with 


occludes 
with 


MANDIBULAR   TEETH 

the  disto-buecal  inclined  plane  of 
the  disto-buecal  cusp  of  the  man- 
dibular  second  molar. 

the  mesio-buccal  inclined  plane  of 
the  mesio-buccal  cusp  of  the  man- 
dibular third  molar. 

the  disto-lingual  inclined  plane  of 
the  disto-buecal  cusp  of  the  man- 
dibular   second    molar. 

the  disto-buecal  inclined  plane  of 
the  disto-lingual  cusp  of  the  man- 
dibular second  molar. 

[  the  mesio-lingual  inclined  plane  of 
'  the  mesio-buccal  cusp  of  the  man- 
dibular   third    molar. 

|  the  mesio-buccal   inclined  plane  of 
J  the  mesio-lingual  cusp  of  the  man- 
dibular   third   molar. 

fthe   disto-bueeal   inclined  plane  of 
I  the  mesio-buccal  cusp  of  the  man- 
dibular   third    molar. 

the  mesio-buccal  inclined  plane  of 
the  disto-buecal  cusp  of  the  man- 
dibular  third   molar. 

the  disto-lingual  inclined  plane  of 
the  mesio-buccal  cusp  of  the  man- 
lil Hilar   third   molar. 


,th 
J  th 


the  disto-bueeal  inclined  plane  of 
the  mesio-lingual  cusp  of  the  man- 
dibular  third   molar. 

the  mesio-lingual  inclined  plane  of 
the  disto-buecal  cusp  of  the  man- 
dibular   third   molar. 

the  mesio-buccal  inclined  plane  of 
the  disto-lingual  cusp  of  the  man- 
dibular   third   molar. 

the  disto-buecal  inclined  plane  of 
the  disto-buecal  cusp  of  the  man- 
dibular third  molar. 


OCCLUSION 


27 


MAXILLARY   TEETH 

The  disto-lingual  inclined  plane 
of  the  disto-buccal  eusp  of  the 
maxillary  third  molar    

The  mesio-buccal  inclined  plane 
of  the  disto-lingual  cusp  of  the 
maxillary   third   molar    

The  mesio-lingual  inclined  plane 
of  the  disto-lingual  eusp  of  the 
maxillary   third  molar    

The  disto-bueeal  inclined  plane 
of  the  disto-lingual  cusp  of  the 
maxillary  third  molar    

The  disto-lingual  inclined  plane 
of  the  disto-lingual  cusp  of  the 
maxillary   third  molar    


MANDIBULAR    TEETH 


occludes 
with 


oceludes 
with 


occludes 
with 


occludes 
with 


occlude 
with 


nothing. 


the  disto-lingual  inclined  plane  of 
the  disto-buccal  cusp  of  the  man- 
dibular  third   molar. 

lie  disto-buccal  inclined  plane  of 
(he  distd-  Lingua]  cusp  of  the  man- 
dibular   third    molar. 


nothing. 


nothing. 


The  tip  of  the  lingual  cusp  of  the  maxillary  premolar  does  not  occlude 
between  the  mandibular  premolars  bu1  occludes  in  the  distal  portion  of 
the  central  fossa  of  the  mandibular  first  premolar.  The  tip  of  the  lin- 
gual cusp  of  the  maxillary  second  premolar  occludes  in  the  distal  portion 
of  the  central  fossa  of  the  mandibular  second  premolar. 

The  maxillary  premolars  are  so  placed  in  the  upper  arch  that  a  line 
drawn  through  the  buccal  and  lingual  ensps  of  the  right  premolars 
would  also  touch  the  buccal  and  lingual  cusps  of  the  corresponding 
teeth  on  the  left  side. 

The  mandibular  premolars  are  so  placed  that  lines  drawn  through  the 
buccal  and  lingual  cusps  of  the  right  and  left  teeth  would  cross  at 
almost  a  right  angle  at  a  point  distal  to  the  teeth. 


NOTE — The  author  prefers  the  terms  first  and  second  incisors  to  those  of  central  and  lateral 
as  it  is  in  keeping  with  first  and  second  molars,  etc.  The  terms  canines  and  premolars  are 
also  more  scientific  and  descriptive  than  cuspids  and  bicuspids.  To  avoid  confusion  both  terms 
are  given  in  the  table. 


CHAPTER  II 
FORCES  OF  OCCLUSION 

It  lias  been  shown  that  each  cusp  lias  a  definite  relation  to  the  op- 
posing cusp,  which  relation  we  have  termed  "occlusion."  Each  tooth 
is  held  in  a  proper  position  by  what  we  call  "forces  of  occlusion." 

Definition. — Forces  of  occlusion  are  those  factors  which  when  acting 
normally  cause  teeth  to  assume  and  maintain  their  position  in  the 
line  of  occlusion.. 

Line  of  Occlusion. — The  line  of  occlusion  is  that  line  with  which, 
in  form  and  position  according  to  type,  the  teeth  must  he  in  harmony 
if  in  normal  occlusion  (Angle).  The  line  of  occlusion  can  also  be 
denned  as  the  line  of  the  greatest  occlusal  contact.  As  each  tooth 
begins  to  make  its  appearance  from  the  dental  crypt  and  gum  it  is 
guided  to  a  certain  position  in  the  dental  arch.  If  all  of  the  forces 
of  occlusion  are  acting  normally,  the  tooth  will  take  its  proper  posi- 
tion, and  if  the  same  forces  of  occlusion  act  normally  during  the  time 
that  the  entire  dental  apparatus  is  forming,  all  of  the  teeth  will  be 
in  their  proper  positions.  However,  should  one  of  the  forces  of  oc- 
clusion become  abnormal  the  result  will  be  malocclusion.  The  failure 
of  any  one  of  the  teeth  to  take  the  proper  position  in  the  line  of  oc- 
clusion will  influence  some  other  tooth  or  teeth  and  malocclusion  will 
result. 

Classification  of  Forces  of  Occlusion 

There  are  six  forces  of  occlusion,  or  factors  of  occlusion,  as  follows: 

1.  Normal  cell  metabolism. 

2.  Muscular  pressure. 

3.  Force  of  the  inclined  plane. 

4.  Normal  approximal  contact. 

5.  Harmony  in  the  size  of  the  arches. 
ii.  Atmospheric  pressure. 

Normal  Cell  Metabolism. -— Th at  normal  cell  metabolism  is  given 
first,  does  no1  necessarily  mean  that  it  is  the  most  important  force. 
for  we  cannot  have  any  one  of  the  forces  abnormal  and  still  have 
normal    occlusion   of   the   teeth.      These    forces   are   given    as   nearh    as 

28 


FORCES    OF    OCCLUSION 


29 


Fig.  8.— Half  of  the  superior  maxilla,  showing  the  growth  downward  and  forward  of  the  alveolar 
process   and   palate.      (After   Noyes.) 


30  PRACTICAL    ORTHODONTIA 

possible   in   the   order   that   they   make   their   appearance   during   the 
time  the  dental  apparatus  is  developing. 

Normal  cell  metabolism  may  be  defined  as  the  proper  physiologic 
development  of  the  cells  that  have  to  do  with  the  eruption  of  the  teeth 
and  the  development  of  the  surrounding  parts.  If  a  child  is  develop- 
ing normally  (Fig.  8),  we  will  have  calcifications  at  the  end  of  the  tooth 
germ,  causing  an  increase  in  the  length  of  the  root  and  absorption  of 
the  bone  forming  the  dental  crypt,  and  the  development  of  the  periden- 
tal membrane.  In  fact,  it  is  the  cell  activity  of  that  particular  region 
which  causes  the  tooth  to  erupt.  Therefore,,  cell  metabolism  is  the  first 
force  which  causes  the  teeth  to  assume  the  proper  position  in  the  dental 
arch. 


Fig.   9. — Malocclusion  of  central   produced  by  abnormal   locking  of  inclined  planes. 

Muscular  Pressure. — It  also  generally  follows  that  teeth,  when  they 
first  erupt,  do  not  always  occupy  their  proper  position.  They  may 
be  too  far  to  the  buccal  or  lingual  side  of  the  arch.  However,  the 
second  force  of  occlusion,  muscular  pressure,  aids  the  tooth  to  take 
very  nearly  the  proper  position  in  regard  to  the  buccal  and  lingual 
relation  to  the  line  of  occlusion.  Should  the  central  incisor  erupt 
too  far  toward  the  Lingual,  the  pressure  of  the  tongue  will  force  it 
labially.  Should  it  be  too  far  toward  the  labial,  the  pressure  of  the 
lips  will  force  it  lingually.  As  a  result  of  the  activity  of  the  muscles 
of  the  cheeks  and  tongue,  we  find  that  each  one  of  the  deciduous  teeth 
is  caused  to  assume  a  position  in  the  areh  in  response  to  those  forces. 
The   muscles   of  mastication    also    influence   the   position   of  the   teeth 


FORCES    OF    OCCLUSION  31 

through  the  relation  of  the  inclined  planes.     Therefore,  muscular  pres- 
sure is  the  second  force  that  has  an  action  upon  the  teeth  that  causes 


Fig.    10. — The  position   of  first  molars   at  this  age   easily   permits   of   abnormal   locking   of   cusps. 


Fig.    11. — Left   side   of   model    shown    in    Fig.    10. 

them  to  take  their  proper  position.     If  everything  is  developing  nor- 
mally, from  this  time  on  the  other  four  forces  of  occlusion  act  so  nearly 


32 


PRACTICAL    ORTHODONTIA 


together  that  it  is  almost  impossible  to  say  which  exerts  an  influence 
first  or  which  is  the  most  important. 

Force  of  the  Inclined  Plane. — The  author  is  inclined  to  believe  that 
the  third   force,  ox  the  force  of  the  inclined  plane,  is  the  next  one  to 


Fig.    12.— Abnormal   locking  of  first   molars  will  produce   other  malocclusions  as  age   advances. 


Fig.    13. — Showing  abnormal   approximal   contacts   of   teeth   and   the   influence   of  one  tooth    on    the 

others. 


be  an  important  factor  as  the  teeth  erupt.  The  force  of  muscular 
pressure  has  caused  the  maxillary  and  mandibular  teeth  to  be  placed  in 
an  arch  which  is  about  the  shape  of  the  tongue  and  which  corresponds 


FORCES    OF    OCCLUSION 


33 


with  the  range  of  the  activity  of  the  muscles  of  the  cheek  and  lip. 
As  the  maxillary  and  mandibular  teeth  approach  each  other,  we  find  that 


Fig.   15. 

Figs.  14  and  15. — Showing  abnormal  locking  of  teeth  and  abnormal  approximal  contacts.  The 
maxillary  right  second  premolar  (bicuspid)  and  maxillary  left  canine  (cuspid)  are  crowded 
lingually   because   of   abnormal    approximal    contact. 

the  inclined  planes  of  the  eusps  of  the  occlusal  surface  come  in  contact, 
act  in  the  nature  of  a  wedge,  and  force  the  teeth  to  such  a  position 


n 


PRACTICAL    ORTHODONTIA 


that  the  cusps  of  the  mandibular  teeth  will  fall  in  the  grooves  and  sulci 
of  the  maxillary  teeth  and  the  cusps  of  the  maxillary  teeth  will  fall  in  the 


Fig.    16. 


Fig.  17. 

Figs.     16    and    17. — Show    malocclusion    resulting    from    missing    left    maxillary    second    premolai 
(bicuspid),    resulting   in    inharmony    in    size    of    arches. 

fossae  and  grooves  of  the  mandibular  teeth  (Fig.  9).    It  has  been  shown 
that  the  mesio-lingual  cusp  of  the  maxillary  molar  occludes  in  the  central 


FORCES    OF    OCCLUSION  35 

fossa  of  the  corresponding  mandibular  molar;  also  that  the  buccal  cusps 
of  the  maxillary  molars  and  premolars  are  buccal  to  the  mandibular  mo- 
lars and  premolars.  Seldom  do  we  find  each  cusp  occupying  its  proper 
position  when  the  cusps  of  the  teeth  first  come  in  contact;  hut  owing  to 
the  act  of  mastication,  the  cusps  force  themselves  into  the  proper  place, 
provided  that  they  have  stinted  in  the  right  direction  (Fig.  10).  How- 
ever, should  one  cusp  be  locked  on  the  wrong  incline  it  becomes  a  factor 
in  producing  malocclusion  (Fig.  12),  and  instead  of  a  normal  occlusion 
of  the  teeth  there  will  he  malocclusion.  The  force  of  the  inclined  plane 
is  active,  from  the  teeth  in  one  arch  to  the  teetli  in  the  opposite  arch. 
We  have  stated  that  the  forces  of  occlusion  are  closely  related,  and 


Fig.     18.  —  Malocclusion    produced    by    missing    lateral. 

this  is  especially  true  in  regard  to  the  force  of  the  inclined  plane  and 
that  of  muscular  pressure.  Muscular  pressure  has  been  defined  as  the 
force  exerted  by  the  muscles  of  the  lips  and  cheeks  upon  the  teeth.  This 
action  is  derived  from  the  muscles  of  respiration,  deglutition  and  ex- 
pression. These  groups  of  muscles  exert  a  direct  force  upon  the  teeth, 
which  is  different  from  the  force  exerted  upon  the  teeth  by  the  muscles 
of  mastication.  The  muscles  of  mastication  exert  force  on  the  teeth 
only  through  the  medium  of  the  inclined  planes,  and  it  is  this  action  of 
the  muscles  that  are  attached  to  the  ramus  which  causes  the  force  of 
the  inclined  plane  to  be  an  active  force.     Therefore,  in  studying  the 


36 


PRACTICAL    ORTHODONTIA 


forces  of  occlusion  we  must  ever  bear  in  mind  the  intimate  relation 
that  exists  between  the  one  and  the  others. 

Normal  Approximal  Contact. — The  force  of  the  approximal  contact 
is  the  force  that  the  approximating  surfaces  of  the  teeth  of  one  arch 
exert  on  the  approximating  surfaces  of  the  same  arch.  It  is  different 
from  the  forces  of  the  inclined  plane,  as  it  acts  only  upon  approxi- 
mating teeth.  For  a  number  of  years  we  failed  to  realize  that  there 
were  certain  cases  in  which  the  force  of  the  inclined  plane  would  be 
normal  but  the  force  of  the  approximal  contact  abnormal,  resulting 
in  troublesome  types  of  malocclusion,  the  treatment  of  which  can  only 
be  successfully  accomplished  by  recognizing  the  ^relation  of  the  ap- 
proximal contact  points  (Fig.  13).  After  one  tooth  in  either  arch 
erupts,  it  has  a  guiding  influence  on  the  approximating  tooth,  helping 


Fig.    19.  ,  Fig.    20. 

Figs.    19   and   20. — Showing   missing   mandibular    second    premolar    (bicuspid). 

to  produce  either  normal  occlusion  or  malocclusion.  If  two  teeth 
have  erupted  and  the  space  remains  between  them  for  the  third  tooth, 
the  third  tooth  is  influenced  by  the  approximating  tooth  on  its  mesial 
and  distal  side  (Figs.  14  and  15).  The  force  of  the  approximal  con- 
tact is  probably  more  important  in  the  eruption  of  the  permanent 
teeth  than  it  is  in  the  eruption  of  the  deciduous  teeth.  It  therefore 
becomes  necessary  that  the  normal  approximal  contact  of  the  decidu- 
ous teeth  must  be  maintained  in  order  that  the  permanent  teeth  will 
erupt  in  their  proper  position  in  the  dental  arch.  A  great  many  cases 
of  malocclusion  are  produced  in  the  permanent  teeth  because  this  con- 
dition has  been  overlooked. 
Harmony  in  the  Size  of  the  Arches. — ''Harmony  in  the  size  of  the 


FORCES    OF    OCCLUSION 


37 


arches"  means  that  the  teeth  in  the  upper  arch  and  the  teeth  in  the 
lower  arch  are  so  arranged  that  when  in  normal  occlusion,  each  one 
occupying  the  proper  position  in  the  line  of  occlusion,  the  line  of 
greatest  occlusal  contact  will  be  the  same  in  both  arches.  If  there 
is  one  more  tooth  in  the  lower  than  in  the  upper  arch  ^(Figs.  16,  17, 
and  18),  it  necessarily  will  produce  inharmony  iifThe  size  of  the  arches, 
resulting  in  malocclusion.  Likewise,  if  there  is  a  missing  tooth  in  the 
lower  arch,  malocclusion  of  the  upper  arch  will  result  (Figs.  19  and 
20).  Malocclusion  may  he  produced  by  inharmony  in  the  size  of  the 
arches  when   the    inharmony    is   the   result   of   the   decay   of   the   teeth, 


Fig.   21. — Inharmony  in  size  of  maxillary  and  mandibular  teeth.      (Ilawley.) 

causing  destruction  of  the  approximal  contact.  Inharmony  in  the  size 
of  the  arches  may  be  the  result  of  inharmony  in  the  size  of  the  teeth. 
One  or  more  teeth  may  be  too  large  or  too  small.  Cases  are  on  record 
where  the  mandibular  incisors  are  too  large  for  the  maxillary  incisors, 
thereby  making  the  establishment  of  normal  occlusion  and  a  normal 
overbite  impossible,  on  account  of  the  abnormal  approximal  contact 
(Fig.  21).  In  other  cases  it  has  been  found  that  the  maxillary  incisors 
would  be  too  large  as  compared  with  the  mandibular  incisors.  Some- 
times the  inharmony  in  the  size  of  the  teeth  may  be  in  the  premolars  or 
canines.  In  those  cases  where  the  inharmony  as  to  size  exists  in  the 
incisor  region,  the  molars  and  premolars  may  be  in  normal  relation 


38 


PRACTICAL    ORTHODONTIA 


with  each  other  and  the  occlusion  of  the  lateral  halves  may  be  normal, 
and  it  is  possible  to  establish  a  normal  occlusion  in  the  molar  and  pre- 
molar region  with  a  normal  relation  of  the  inclined  planes  and  normal 
approximal  contact  of  the  premolars  and  molars  and  have  a  compro- 
mise occlusion  of  the  incisors.  There  may  be  a  slight  overlapping,  a 
slight  spacing,  or  a  too  short  or  too  great  overbite,  which  is  the  result 


Fig. 


-Posterior    portion    of    nasal    cavity    and    sinuses.      Note    position    of    lingual    cusp    of 
upper  molar. 


of  inharmony  in  the  size  of  the  arches  and  which  must  be  considered  as  a 
force  of  occlusion  that  will  always  assert  itself  in  some  way.  If  there  is 
an  inharmony  in  the  size  of  teeth  it  can  be  compensated  by  grinding  the 
tooth  so  as  to  reduce  the  mesio-distal  diameter  and  thereby  establish 
new  approximal  contacts  and  a  harmony  in  the  size  of  the  arches.  This 
inharmony  in  the  size  of  the  teeth  was  first  called  to  my  attention  by 
Hawley  and  has  later  been  proved  by  the  work  of  Stanton,  Rudolph 


FORCES    OF    OCCLUSION 


39 


Banau,  and  Gilbert  I).  Fish.     Their   work  proves  that  the  forces  of 

occlusion  cannot  be  overlooked  if  we  hope  to  establish  normal  occlusion. 
So  it  will  be  seen  that   \cvy  often    in   the  loss  of  one  of  the  forces 
of  occlusion  a  second  one   is  also  disturbed,  finally  causing  an  inhar- 
monious action  of  all  of  them. 


Fig.   23. --Typical   case'  of  malocclusion  by  mouth-breathing. 

n 


Fig.  24-A.  Fig.  24-B. 

Figs.  24-A  and  24-B. — Facial  deformity  associated  with  mouth-breathing. 

Normal  Atmospheric  Pressure. — By  normal  atmospheric  pressure  is 
meant  the  atmospheric  relations  or  conditions  which  exist  in  the  nasal 
and  oral  cavities  during  normal  breathing,  and  the  changes  which  occur 
in  deglutition  and  when  speaking. 


40  PRACTICAL    ORTHODONTIA 

With  the  lips  closed  and  after  swallowing,  the  soft  palate  is  in  con- 
tact with  the  posterior  portion  of  the  tongue,  and  a  vacuum  is  created 
between  the  center  of  the  tongue  and  the  center  of  the  roof  of  the  mouth. 
As  a  result  of  this,  the  air  from  the  nasal  cavities  makes  a  downward 
pressure  on  the  floor  of  the  nose,  and  becomes  a  factor  in  the  downward 
development  of  the  roof  of  the  mouth.  The  air  pressure  is  also  exerted 
on  the  soft  tissue  beneath  the  chin ;  namely,  the  muscles  running  from 
the  mandible  to  the  hyoid  bone,  and  the  soft  tissues  are  held  in  place  or 
pushed  upward,  which  gives  a  square  effect  to  the  chin  that  is  present 
in  the  normal  breather  and  not  found  in  the  mouth-breather.  The  man- 
dible is  also  held  in  place  by  this  atmospheric  pressure,  as  a  result  of 
a  vacuum  created  between  the  tongue  and  the  roof  of  the  mouth,  and  is 
not  held  in  position  by  the  muscular  action  of  the  elevators  of  the  man- 
dible or  the  muscles  of  mastication,  which  can  be  proved  by  the  simple 
experiment  of  separating  the  lips  and  breathing  through  the  mouth,  and 
noting  the  difficulty  in  keeping  the  mandible  in  position.  If  the  indi- 
vidual breathes  through  the  nose,  with  each  inspiration  and  expira- 
tion a  pressure  is  exerted  on  all  sides  of  the  nasal  cavity.  Not  only  is 
a  pressure  exerted  in  the  nasal  cavity,  but  it  is  also  produced  in  all  of 
the  nasal  sinuses  (Fig.  22).  As  a  result  of  atmospheric  pressure  the 
nasal  cavity  is  developed  to  its  proper  size,  consequently  this  pressure 
plays  an  important  part  in  the  development  of  the  dental  arch.  In  nor- 
mal breathing,  the  proper  action  of  the  muscles  of  the  lips,  cheeks  and 
tongue  is  present,  which  results  in  the  proper  muscular  pressure;  there 
fore,  with  the  loss  of  normal  breathing,  muscular  pressure  is  disturbed, 
causing  two  forces  of  occlusion  to  be  perverted.  Such  resulting  maloc- 
clusions as  we  find  in  distoclusion  with  labioversion  of  the  maxillary  an- 
terior teeth  (Fig.  23)  are  primarily  the  result  of  disturbed  atmospheric 
pressure  and  abnormal  pressure  of  the  cheeks,  lips,  and  tongue  (Fig. 
24).  Another  very  important  phase  of  atmospheric  pressure  or  con- 
ditions and  muscular  action  takes  place  after  we  cease  speaking — we 
close  the  lips  and  swallow;  a  vacuum  is  created  in  the  oral  cavity  which 
in  turn  forces  the  tongue  up  against  the  roof  of  the  mouth  and  exerts 
pressure  upon  the  maxillary  and  mandibular  teeth.  In  mouth-breath- 
ing the  tongue  exerts  a  pressure  only  on  the  mandibular  arch  and 
mostly  upon  the  mandibular  molars  and  premolars.  Atmospheric  pres- 
sure is  an  active  force  during  the  whole  time  that  the  individual  is 
breathing.  If  at  any  time  breathing  becomes  abnormal  and  the  at- 
mospheric pressure  is  disturbed,  malocclusion  will  result.  Should  chil- 
dren become  mouth -breathers  early,  malocclusion  will  develop  shortly 


FORCES    OF    OCCLUSION  41 

after  the  mouth-breathing  begins.  Any  of  these  forces  of  occlusion 
acting  in  the  wrong  direction  then  become  forces  of  malocclusion.  Ac- 
quired cases  of  malocclusion  are  simply  the  result  of  some  condition  that 
has  resulted  from  one  or  more  of  the  forces  of  occlusion  that  have  been 
disturbed.  Therefore,  it  becomes  imperative  that  any  effort  toward  the 
correction  of  malocclusion  must  he  of  such  a  nature  that  it  will  not  only 
place  the  teeth  in  their  proper  position  in  the  line  of  occlusion  but,  if 
they  are  expected  to  stay  there,  all  six  of  the  forces  of  occlusion  must  be 
normal  and  remain  normal. 


CHAPTER  III 
MALOCCLUSION 

Malocclusion  is  the  deviation  from  normal  occlusion  to  such  an  ex- 
tent as  to  interfere  with  the  proper  functions  of  the  teeth. 

Malocclusion  may  be  divided  into  four  groups :  First,  positions,  of 
individual  teeth  that  deal  with  the  relation  of  the  tooth  to  the  ap- 
proximating teeth,  the  line  or  plane  of  occlusion,  and  the  median  line 
of  the  face.  Lischer  terms  this  group  "malpositions  of  the  individual 
teeth."  The  second  group  is  the  relation  of  one  arch  to  the  other, 
"malrelation  of  the  arches,"  which  is  based  on  the  antero-posterior 
relation  or  the  mesio-distal  relation  of  the  mandibular  arch  to  the  max- 
illary arch.  Third,  we  have  "malposition  of  the  mandible,"  which  is 
based  on  the  relation  that  the  mandible  bears  to  the  face  and  cranium, 
especially  the  relation  that  the  condyle  bears  to  the  glenoid  fossa.  The 
fourth  division  includes  "malformation  of  the  jaws  and  processes," 
which  includes  deformities  of  the  mandible  and  maxilla?. 

Positions   of  Malocclusion,   or  Malpositions   of   the   Teeth 

"Positions  of  Malocclusion"  deal  with  the  individual  teeth  or  the 
relation  of  the  teeth  of  one  arch  to  the  approximating  teeth  of  the 
same  arch.  The  positions  of  malocclusion  may  be  denned  as  the  rela- 
tion of  the  individual  teeth  to  the  line  or  plane  of  occlusion  and  the 
median  line  of  the  face. 

In  order  to  be  perfectly  clear  on  this  subject,  we  might  again  state 
that  the  line  of  occlusion  is  that  line  with  which,  in  form  and  position 
according  to  type,  the  teeth  must  be  in  harmony  if  in  normal  occlu- 
sion (Angle). 

There  are  seven  distinct  positions  of  malocclusion  (Fig.  25),  named 
from  the  position  which  the  teeth  occupy  to  the  line  or  plane  of  occlusion 
and  to  the  median  line  of  the  face.  The  line  of  occlusion  is  divided  into 
the  right  and  left  half  by  the  median  line  of  the  face. 

A  tooth  that  is  too  near  the  median  line  of  the  face  or  too  far  to- 
ward the  middle  of  the  arch  is  said  to  be  in  mesial  occlusion  or  mcsio- 
version.* 


*L,ischer  has  suggested  the  use  of  the  ending  "version"  to  apply  to  the  malposition  of  the 
teeth,  which  ending  is  less  confusing  than  occlusion,  the  latter  term  being  limited  by  L,ischer 
to  refer  to  the  malrelation  of  the  arches. 

42 


MALOCCLUSION 


43 


One  that  is  too  far  in  the  opposite  direction  or  toward  the  posterior 
portion  of  the  arch  is  in  distal  occlusion,  or  distoversion. 

A  tooth  that  is  too  far  toward  the  lips  or  cheeks  is  in  labial  or  buccal 
occlusion,  or  labioversion  or  buccoversion.  Labial  occlusion  orlabiover- 
sion  is  applied  to  the  six  anterior  teeth  and  buccal  occlusion,  or  buccover- 
sion, to  the  posterior  teeth. 

A  tooth  that  is  too  far  to  the  Ungual  side  of  the  line  of  occlusion  is  said 
to  be  in  lingual  occlusion,  or  linguoversion. 

One  that  is  too  short,  that  is,  that  has  not  erupted  far  enough  to  reach 
the  plane  of  occlusion,  is  in  infra-occlusion,  or  in fr aversion. 


BO. 


Fig     25. — Positions   of   malocclusion.      Heavy    black    lines   indicate    normal    position.      Dotted    lines 
indicate   positions   of   malocclusion. 
La.   O. — Labial   occlusion.     Labioversion. 
L.    O. — Lingual   occlusion.      Linguoversion. 
T.    O. — Torsi-occlusion.      Torsiversion. 
D.   O. — Distal   occlusion.      Distoversion. 
M.    (  ). — Mesial     occlusion.       Mesioversion. 
B.    O. — Buccal   occlusion.      Buccoversion. 
M.    La.    O. — Mesio-labial    occlusion.      Mesiolabioversion. 


One  that  has  grown  too  long  is  in  supra-occlusion,  or  supraversion. 

A  tooth  that  does  not  occupy  a  proper  axis  in  the  line  of  occlusion  is 
said  to  be  in  torsi-occlusion,  or  torsiversion,  that  is,  rotated  on  its  axis. 

Lischer  suggests  the  term  transversion  for  teeth  that  are  transposed; 
for  example,  when  the  canine  is  between  the  premolars,  lie  also  uses  the 
term  perversion  for  impacted  teeth. 

We  also  have  various  combinations  of  these  positions,  for  a  tooth  may 
be  too  far  mesial  and  also  rotated  ;  it  would  then  be  in  torsi-mesioversion. 
Likewise,  it  may  be  in  any  of  the  other  four  positions.  A  tooth  may  be 
in  mesial  occlusion,  or  mesioversion,  not  erupted  far  enough  and  also  ro- 
tated, in  which  case  it  would  be  in  mesio-torsi-infra-occlusion.,  or  mesio- 


44 


PRACTICAL    ORTHODONTIA 


torsi-infraversion.  Various  combinations  will  result  from  various  posi- 
tions of  the  teeth.  A  tooth  may  be  too  far  mesial,  may  be  rotated,  may 
be  in  infra-occlusion,  or  infraversion,  and  also  occupy  a  labial  position, 
in  which  case  it  is  spoken  of  as  being  in  miesio-labio-torsi-infra-occlimon, 
or  as  being  in  mesio-labio-torsi-infraversion. 


Fig.  26-A. 


Fig.  26-B. 

Figs.    26-A    and    26-B. — Maxillary    and    mandibular    molars    and    premolars    are    in    linguoversion. 
Lateral  incisors  are  in   linguo-torsioversion. 

With  the  seven  primary  positions  of  malocclusion  it  is  possible  for 
a  tooth  to  occupy  four  of  them  at  one  time.  To  move  a  tooth  into  the 
proper  position,  it  would  necessarily  have  to  be  moved  in  four  different 
directions.  So  positions  of  malocclusion  while  comparatively  simple 
offer  various  complications  in  treatment  (Fig.  26). 


MALOCCLUSION  45 

Classification  of  Malocclusion,  or  Malrelation  of  the  Arches 

Classes  of  malocclusion  deal  with  the  relation  of  the  mandibular  teeth 
to  the  maxillary  teeth.  Of  course,  the  positions  of  malocclusion  have 
some  relation  in  the  formation  of  the  class,  the  principal  one  being  the 
mesial  and  distal  (anterior  and  posterior)  relation  of  the  arches.  We 
have  shown  in  the  study  of  normal  occlusion  that  the  mesio-buccal  cusp 


A  B 

Fig.  27. — Diagram  A  illustrates  normal  arch  relationship.  In  Diagram  B,  the  parallelogram 
a,  b,  c.  d,  illustrates  arch  malrelation  in  bilateral  mesioclusion,  and  b,  y,  their  relation  in 
bilateral  distoclusion.     (Uscher.) 


Fig.   28. — Diagrams   illustrating  arch  malrelations   in   unilateral   distoclusion   and   unilateral   mesio- 
clusion.     (Lischer.) 

of  the  maxillary  first  molar  occludes  in  the  buccal  groove  of  the  mandib- 
ular first  molar.  Also,  the  mesio-lingual  cusp  of  the  maxillary  first 
molar  falls  into  the  central  fossa  of  the  mandibular  first  molar,.  The 
maxillary  canine  occludes  between  the  mandibular  canine  and  the  man- 
dibular first  premolar.  The  relation  of  the  mesio-buccal  cusp  of  the 
maxillary  first  molar  to  the  buccal  groove  has  been  called  by  Angle  the 


46 


PRACTICAL    ORTHODONTIA 


Fig.    29.     Neutroclusion,    oi     Class    I     (Angle),    showing    normal    mesio-distal    (antero-posterior) 

relation   of   arches. 


Fig.    30.     Another    type    of    neutroclusion    01     normal    mesio-distal    (antero-posterior)    relation    ol 

arches. 


MALOCCLUSION  47 

"Key  tn  Occlusion."  Other  cusps  are  just  as  important,  but  we  must 
select  some  definite  points  and  keep  them  in  mind  in  deciding  whether 
the  teeth  occupy  a  proper  mesio-distal  relation  to  the  opposing  teeth. 
We  must  take  into  consideration  more  than  one  tooth  in  order  that  we 
may  decide  whether  the  dental  arches  occupy  their  proper  mesio-distal 
(antero-posterior)  relation  to  each  other,  for  classification  of  malocclu- 
sion depends  upon  whether  the  arches  occupy  a  normal  mesio-distal  re- 
lation or  are  too  far  forward  or  too  far  hack.  As  the  mandibular  teeth 
are  the  movable  arch,  we  speak  of  them  as  being  in  normal  mesio-distal 
(antero-posterior)  relation  to  tKe  upper  areh.  or  as  being  in  distal  I  pos- 
terior) relation  to  the  upper  arch,  or  as  being  in  mesial  (anterior)  rela- 
tion to  the  upper  arch.  Following  tins  plan,  malocclusion  of  the  arches 
can  therefore  be  divided  into  three  general  classes.  By  three  classes,  we 
mean  thai  in  all  cases  of  malocclusion  the  lower  arch  must  either  be 
normal  mesio-distally,  or  the  lower  arch  distal  (posteriori  or  mesial 
(anterior)  to  the  upper.  Therefore,  one  group  of  cases  would  in- 
clude those  in  which  there  is  a  distal  (posterior)  relation  of  the  lower 
arch  to  the  upper,  and  another  group  would  include  those  in  which 
the  mandibular  teeth  are  mesial  (anterior)  to  the  upper,  while  still 
another  group  would  include  all  of  those  cases  in  which  the  lower 
arch  is  neither  mesial  (anterior)  nor  distal  (posterior),  but  is  normal 
in  these  relations 

The  mesio-distal  relation  cf  the  arches  can  he  illustrated  by  the 
use  of  curves  or  arches  that  represenl  the  upper  and  lower  dental 
arch.  In  Pig.  28  b-c  represents  the  upper  arch  and  a-d  the  lower  arch. 
The  Diagram  A  represents  the  normal  mesio-distal  (antero-posterior) 
relation  of  the  arches.  The  lines  a  to  6  and  c  to  d  represent  the  normal 
relation  of  the  lower  arch  to  the  upper.  In  Diagram  B  the  lines  a  to  b 
and  c  to  d  represent  what  would  happen  if  the  lower  arch  was  moved 
forward  or  mesially.  The  lines  b  to  y  and  c  to  w  represent  the  relations 
of  the  lower  arch  to  the  upper  if  a  distal  or  backward  movement  was 
to  take  place.  Cases  of  malocclusion  that  involve  the  mesial  or  distal 
malposition  of  the  arches  are  spoken  of  as  bilateral  cases.  In  some  in- 
stances the  lower  arch  is  shifted  forward  or  backward  on  one  side  only. 
Diagram  A,  Fig.  28,  shows  the  change  in  the  lines  a  to  &  in  the  distal 

or  backward  movement  of  the  lower  arc! ue  side  as  compared  with 

the  normal  relations  as  shown  in  Diagram  A,  Fig.  27.  Diagram  B,  Fig. 
28,  to  show  the  change  that  would  occur  in  the  mesial  or  forward  move- 
ment of  one  side  of  the  arch,  eompare  the  lines  a  to  b  (Diagram  B,  Fig. 


48 


PRACTICAL    ORTHODONTIA 


Fig.    31. 


Fig.  32. 

Figs.    31    and    32. — Normal    mesio-distal    relation    of   arches    with    lingual    occlusion    of    right    max- 
illary  molars   and    premolars    (bicuspids)    to    lowers.      Neutroclusion,    or    Class    I,    case. 


MALOCCLUSION 


49 


28)  with  the  same  lines  in  Diagram  A,  Fig.  27.  Cases  of  malocclusion 
which  are  mesial  or  distal  on  one  side  only  are  called  unilateral  cases. 
The  malrelation  of  the  arches  is  thcrefore_based_on  the  mesio-distal  or 
antero-posteHor  relation  of  the  lower  to  the  upper.  If  both  sides  of 
the  lower  arch  are  distal  to  the  upper,  we  speak  of  it  as  a  bilateral  dis- 
tal occlusion  of  the  lower  arch.  If  one  side  only  of  the  lower  is  distal 
to  the  normal  relation  of  the  upper  we  call  such  a  case  a  unilateral 
distal  occlusion  of  the  lower  arch.  On  the  other  hand,  if  the  lower 
arch  is  mesial  to  the  upper  arch  on  both  sides,  we  refer  to  it  as  a 


Fig.    33. — Abnormal    mesio-distal    relation    of    first    permanent     molars    with     normal    mesio-distal 
(antero-posterior)    relation   of    arches.      Neutroclusion,    or    Class    I,    case. 

bilateral  mesial  occlusion.     If  the  lower  arch  is  mesial  on  one  side  only 
it  is  referred  to  as  a  unilateral  mesial  occlusion  of  the  lower  arch. 

As  a  result  of  this  plan  of  classification,  all  cases  of  malocclusion  will 
fall  in  one  of  the  three  groups  that  have  been  mentioned,  which  are 
based  on  the  mesio-distal  relation  of  the  arches.  Various  efforts  have 
been  made  to  apply  some  short  term  to  these  groups  of  malocclusion 
so  that  it  would  be  simple  and  easy  to  designate  each  case  of  maloc- 
clusion to  its  proper  group.  Angle  used  the  numerals,  I,  II,  III, 
which  is  a  satisfactory  way  to  designate  the  groups  for  one  who  has 
first  learned  the  characteristics  of  each  group.  Better  and  more  de- 
scriptive terms  have  been  suggested  by  Lischer,  and  adopted  by  the 


50 


PRACTICAL    ORTHODONTIA 


Fig.  34. — Maxillary  left  second  premolar  impacted  l<y  the  drifting  of  molars  mesially,  due  to 
early  loss  of  deciduous  molar.  Arch  relations  normal  mesio-distally  (anteroposterior).  Neu- 
troclusion,  or  Class  I,  case. 


Fig.    35. — Showing   position    of    impacted    premolar    (bicuspid). 

American  Society  of  Orthodontists,,  which  arc  neutroclusion,  distoelu- 
sion,  and  mesioclusio.n.  The  relation  of  the  two  set  of  terms  is  shown 
below. 


A.NGLE 


LlSCHER 


Class  I  is  tlic  same  as  Neutroclusion 
Class  II  is  tlic  same  as  Distoclusion 
Class  III  is  the  same  as  Mesioclusion 


Believing,  from  experience  with  students,  that  Liseher's  terms  are 
more  descriptive,  tlic  author  would  suggest  their  general  use;  and 
throughout  this  work  they  will  he  used  in  conjunction  with  Angle's 
numerals. 


M  \l.(>(  rUSloX 


51 


Fig.   36. — Mutilated   case   of   Neutroclusion,   or   Class   I. 


Fig.    37. — Class   I,   Type    1,   case.      Neutroclusion    with   bunched    anterior   teeth,    or    Complex    Neu- 
troclusion   (Lischer). 


52 


PRACTICAL    ORTHODONTIA 


Neutroclusion,  or  Class  I 

Neutroclusion,  or  Class  I,  cases  are  those  which  present  a  normal 
mesio-distal  relation  of  the  arches  (Figs.  29  and  30).  The  anterior 
teeth  may  occupy  any  of  the  seven  positions  of  malocclusion,  although 
the  majority  of  neutroclusion,  or  Class  I,  cases  show  bunching  of  the 
anterior  teetlr  Some  of  the  teeth  are  in  torsi-lingual  occlusion,  while 
others  may  be  in  labial  occlusion.  There  is  usually  a  narrowing  of 
the  upper  and  lower  arches,  which  would  mean  that  the  molars  and 
premolars  are  in  lingual  occlusion.  The  one  outstanding  feature  that 
is  normal,  regarding  the  teeth  in  this^class,  is  that  there  must  be  a 
normal  mesio-distal  relation  of  the  arches  as  indicated  by  the  occlusal 


Fig.    38. — Class   I,   Type  2   case.      Normal   mesio-distal   relation    of   arches.      Protrusion    (labial   oc- 
clusion)    of    maxillary    incisors.    Neutroclusion    with    labioversion    of    maxillary    incisors. 

relation  of  the  upper  and  lower  first  molars.  If  all  of  the  teeth  are 
present,  it  will  be  equivalent  to  saying  that  we  have  a  normal  mesio- 
distal  relation  of  the  molars.  One  or  both  sides  of  the  molars  may  be 
in  lingual  occlusion,  or  linguoversion  (Figs.  31  and  32).  It  must  also 
be  remembered  that  a  normal  mesio-distal  relation  of  the  arches  does 
not  necessarily  imply  a^JiormaL  mesio-distal  relation  of  the  molars. 
Owing  to  the  early  loss  of  the  deciduous  molar,  as  shown  in  Fig.  33, 
the  first  permanent  molar  on  the  right  side  has  drifted  mesially,  while 
all  of  the  other  teeth  have  a  normal  mesio-distal  relation  to  each  other, 
which  shows  a  normal  mesio-distal  relation  of  the  arches.    Fig.  34  shows 


MALOCCLUSION 


53 


a  case  of  an  older  patient,  also  caused  by  the  drifting  of  the  upper  molar 
forward  as  a  result  of  the  loss  of  the  deciduous  molar.    Fig.  35  shows 


Fig.    39. 


Fig.  40. 

Figs.  39  and  40. — Class  I,  Type  3  case.  Normal  mesio-distal  relation  of  arches  with  linguo- 
version  of  maxillary  incisors  to  lowers.  Also  slight  mesial  occlusion  of  mandibular  in- 
cisors caused  by  abnormal  force  of  the  inclined  planes  of  anterior  teeth.  Netroclusion  with 
linguoversion   of   maxillary   anterior   teeth. 

the  occlusal  view  of  the  case.  Again  there  is  a  normal  relation  of  the 
arches,  but  not  of  the  molars.  Therefore,  both  of  these  cases  (Figs.  33 
and  34)   are  neutroclusion,  or  Class  I,  cases. 


54  PRACTICAL    ORTHODONTIA 

Neutroclusion,  or  Class  I,  Mutilated  Cases. — If  any  of  the  teeth 
have  been  extracted  or  are  missing,  we  shall  often  find  in  these  cases 
a  normal  mesio-distal  relation  of  archers,  and  not  necessarily  a  normal 
mesio-distal  relation  of  the  molars  and  remaining  teeth  (Fig.  33).  In 
classifying  cases  where  there  is  a  normal  mesio-distal  relation  of  the 
arches  and  some  of  the  teeth  have  been  lost  by  extraction,  we  have 
to  resolve  the  condition  to  what  it  was  before  the  loss  of  the  tooth, 
whether  it  is  a  premature  loss  of  a  deciduous  tooth  or  the  loss  of  a  per- 
manent tooth.  Such  cases  as  have  been  described  above  are  spoken  of 
and  classified  as  neutroclusion,  multilated,  or  Class  1,  mutilated  (Fig. 
36). 

Types  of  Neutroclusion,  or  Class  I. — Neutroclusion  presents  several 
different  types  that  demand  special  mention  because  they  present  char- 


Fig.    41. — Class    I,    Type   3    case.      Neutroclusion   with    linguoversion    of   upper    anterior   teeth. 

acteristics  that    demand   special   treatment.     For  convenience  we  have 
designated  them  as  Types  1,  2,  and  3  of  Neutroclusion. 

Neutroclusion  with  Bunched  Anterior  Teeth,  or  Class  I,  Type  1.— 
These  cases  are  characterized  by  a  normal  mesio-distal  relation  of  the 
arches  (Figs.  'J!)  and  30).  All  of  the  teeth  are  in  linguoversion  or  lin- 
gual occlusion  except  that  in  certain  cases  we  find  some  or  all  of  the 
canines  in  labioversion  or  labial  occlusion  (Fig.  37).^.  The  upper  and 
lower  molars  and  premolars  are  in  linguoversion  or  lingual  occlusion 
and  demand  expansion.  The  maxillary  molars  and  premolars  may  be 
in  lingual  occlusion  to  the  mandibular  molars  and  premolars  on  one  or 
both  sides. 


M  ULiOCCLUSION 


:,:, 


Fig.  42. — Class  II,  Division  1  case.  Bilaterally  distal  (posterior)  relation  of  lower  arch. 
Narrow  upper  arch.  Protruding  maxillary  anterior  teeth.  Distoclusion  with  Iabioversion  of 
maxillary  anterior  teeth. 


Fig.    43. 


-Class    II.    Division    1    case.      Bilaterally    distal    relation    of   lower   arch.      Bilateral    disto- 
clusion   with    Iabioversion    of    maxillary    anterior   teeth. 


56 


PRACTICAL    ORTHODONTIA 


There  is  a  condition  of  the  teeth  that  might  be  described  as  "bunched." 
These  cases  may  be  called  complex  neutroclusion. 

Neutroclusion  with  Labioversion  of  Upper  Incisors,  or  Dlass  I,  Type 
2. — Cases  belonging  to  this  type  are  characterized  by  a  normal  mesio- 
distal  relation  of  the  arches,  protruding  maxillary  anterior  teeth  (Fig. 
38),  bunched  mandibular  anterior  teeth  and  narrow  upper  and  lower 
arches.  The  maxillary  and  mandibular  molars  and  premolars  usually 
occupy  the  proper  bucco-lingual  relation  to  each  other.  The  patient  is 
or  has  been  at  some  time  a  mouth-breather,  or  has  a  lip-habit. 


Fig.  44. 


Fig.  45. 


Figs.   44   and   45. — Class   II,   Division    1   case.      Malocclusion    shown   in    Fig.    43.      Short   upper   lip, 
abnormal    muscular    pressure,    mouth-breathing. 


Neutroclusion  with  Linguoversion  of  Upper  Anterior  Teeth,  or  Class 
I,  Type  3. — Here  we  find  a  normal  mesio-distal  relation  of  the  arches 
(Fig.  39).  The  maxillary  incisors  are  in  linguoversion  or  lingual  oc- 
clusion to  the  mandibular  ..(Fig.  40),  with  bunching  of  the  maxillary  a4i- 
terior  teeth  and  lack  of  development  in  the  premaxillary  region.  -  The 
teeth  of  the  mandibular  arch  may  be  bunched  or  occupy  a  nearly  normal 
approximal  relation  to  each  other  (Fig.  41).  The  lower  lip  appears  prom- 
inent because  the  upper  lip  is  underdeveloped  as  a  result  of  the  position 
of  the  maxillary  teeth. 

Any  of  these  types  of  neutroclusion,  or  Class  I,  may  be  complicated 
by  mutilations. 


MALOCCLUSION 


57 


Fig.    46. 


Fig.  47. 

Figs.   46   and   47. — Class   II,    Division   2   case.      Bilaterally   distal    (posterior)    relation    of   lower 
arch.      Retruding    or    bunched    maxillary    incisors.    Distoclusion    with    linguoversion    of    maxillary 


58  PRACTICAL    ORTHODONTIA 

Distoclusion,  or  Class  II 

Distoclusion,  or  Class  II,  cases  of  malocclusion  are  those  that  are 
characterized  by  a  distal  (posterior)  relation  of  the  lower  arch,  (lass 
II  cases  are  divided  into  Division  1  (Angle),  or  distoclusion,  with  labio- 
version  of  the  maxillary  anterior  teeth  (Lischer)  ;  and  Class  II 
Division  2  (Angle),  or  distoclusion  with  linguoversion  of  the  maxillary 
anterior  teeth   (Lischer). 

Distoclusion  With  Labioversion  of  Maxillary  Incisors,  or  Class  II, 
Division  1. — Division  1  cases  are  those  that  are  characterized  by  a  dis- 
tal relation  of  the  lower  arch  to  the  upper,  the  width  of  a  premolar 
(Figs.  42  and  43).  Instead  of  the  mesio-buccal  cusp  of  the  maxillary 
first  molar  occupying  a  mesio  distal  relation  corresponding  to  the  buc- 
cal groove  of  the  mandibular  first  molar,  we  find  it  occupying  a  mesio- 
distal  relation  corresponding  to  the  buccal  embrasure  between  the 
mandibular  first  molar  and  mandibular  second  premolar.^  The  other 
characteristics  of  Class  II,  Division,  1,  are  as  follows :  A  narrow  upper 
arch,  protruding  anterior  teeth,  a  mandible  that  is  deficient,  an  un- 
derdeveloped or  receding  chin,  abnormal  muscular  pressure,  a  short 
upper  lip  and  mouth  breathing  (Figs.  44  and  45).  Mouth-breathing 
has  disturbed  the  other  forces  of  occlusion,  especially  muscular  pres- 
sure, which  has  resulted  in  allowing  the  maxillary  anterior  teeth  to 
protrude  in  the  upper  arch  and  in  permitting  them  to  remain  in  an 
undeveloped  condition  bucco-lingually.  The  underdeveloped  mandible 
and  the  receding  chin  are  the  result  of  the  distal  occlusion  of  the 
mandibular  teeth  and  the  abnormal  action  of  the  muscles. 

Distoclusion  With  Linguoversion  of  Upper  Anterior  Teeth,  or  Class 
II,  Division  2.— (Mass  II,  Division  2  (Figs.  46  and  47)  is  characterized 
by  the  distal  relation  of  the  lower  arch  to  the  same  extent  as  in  Di- 
vision 1.  The  other  characteristics  are  directly  the  opposite.  We 
have  an  upper  arch  that  is  nearly  normal  in  width  with  retruding  and 
bunched  anterior  teeth.  The  mandible  is  more  nearly  normally  de- 
veloped and  the  chin  is  not  receding.  We  have  normal  pressure  of 
the  lips  and  cheeks  and  normal  action  of  the  tongue  and  normal 
breathing.  The  difference  between  Division  1,  (Mass  II,  and  Division 
2,  Class  II,  is  the  result  of  the  difference  between  normal  and  abnormal 
muscular  pressure.  In  order  to  more  clearly  enumerate  the  differences 
between  Division  1  and  Division  2,  they  are  given  in  tabulated  form 
opposite  each  other  in  the  following  table; 


MALOCCLUSION 


59 


Fig.  48. 


Fig.   49. 

Figs,  49  and  50. — Class  II,  Division  1,  Subdivision.  Unilaterally  distal  (posterior)  relation  of 
lower  arch  (left  side  of  lower,  distal;  right  side,  normal).  Protruding  superior  anterior  teeth. 
Unilateral    distoclusion    with    labioversion    of   maxillary    anterior    teeth. 


60 


PRACTICAL    ORTHODONTIA 


Class  II 


division  1. 

Bilaterally  distal  relation  of  the 
lower  arch. 

Protruding   anterior    maxillary    teeth. 

Narrow   upper   arch. 

Undersized  ehin. 

Undersized  mandible. 

Abnormal  muscular  pressure. 

Abnormal  atmospheric  pressure. 

Mouth-breathing. 

Subdivision    of   Class   II,   Division    I. 

Unilaterally  distal  with  the  same 
characteristics   as  Division    1. 

One  side  of  the  lower  arch  is  in  nor- 
mal mesio-distal  relation  to  the 
upper. 


division  2. 

Bilaterally  distal  relation  of  the 
lower  arch. 

Retruding  and  bunched  maxillary  an- 
terior teeth. 

Upper   arch   nearly  normal  in  width. 

Normal-sized  chin. 

Normal-sized   mandible. 

Normal  muscular  pressure. 

Normal  atmospheric  pressure. 

Normal  breathing. 

Subdivision   of   Class   II,   Division   2. 

Unilaterally  distal  with  the  same 
characteristics    as   Division   2. 

One  side  of  the  arch  is  in  normal 
mesio-distal   relation   to   the   upper. 


Both  Division  1  and  Division  2  of  Class  II  sometimes  show  a  distal 
relation  of  the  lower  arch  present  on  one  side  only.  It  may  be  on 
either  the  right  or  the  left  side  according  as  the  etiological  factors 
have  been  present.  These  cases  of  Division  1  and  Division  2  are 
therefore  called  subdivisions,  or  unilateral  distoclusions,  and  are 
named  as  Class  II,  Division  1,  Subdivision;  or  Class  II,  Division  2, 
Subdivision ;  or  just  reversing  them  and  saying  Subdivision  of  Di- 
vision 1  of  Class  II,  or  Subdivision  of  Division  2  of  Class  II.  These 
subdivisions  are  spoken  of  as  being  unilaterally  distal.  The  other 
characteristics  are  exactly  the  same  as  found  in  Division  1  and  Di- 
vision 2  (as  shown  in  table).  For  example,  a  subdivision  of  Division 
1,  Class  II  (Figs.  48  and  49)  would  be  a  case  in  which  Ave  had  a  nor- 
mal mesio-distal  relation  of  the  arches  on  one  side,  with  a  distal  rela- 
tion of  the  lower  arch  on  the  other,  a  narrow  upper  arch,  protruding 
anterior  teeth,  an  underdeveloped  mandible,  a  receding  chin,  abnor- 
mal muscular  pressure  and  abnormal  breathing.  A  subdivision  of 
Division  2  of  Class  II  (Figs.  50  and  51)  would  be  a  case  in  which  the 
lower  arch  was  distal  on  one  side,  on  the  other  side  normal  mesio- 
distally,  an  upper  arch  nearly  normal  in  width,  retruding  and  bunched 
maxillary  incisors,  a  mandible  of  nearly  normal  size,  a  normal  chin, 
normal  muscular  pressure,  normal  atmospheric  pressure  and  normal 
breathing.  It  does  not  matter,  so  far  as  the  classification  is  concerned, 
whether  the  right  or  left  side  in  these  subdivision  cases  is  normal  or 
abnormal  mesio-distally  (Figs.  52  and  53). 


MALOCCLUSION 


61 


Fig.  SO. 


Fig.  51. 

Figs.  50  and  51. — Class  II,  Division  2,  Subdivision.  Unilaterally  distal  relation  of  lower 
arch.  Right  side,  normal;  left  side,  distal.  Bunched  superior  anterior  teeth.  Unilateral  disto- 
clusion   with   linguoversion   of   maxillary    incisors. 


62 


PRACTIC  \L    ORTHODONTIA 


Fig.  52. 


Fig.  53. 

Figs.  52  and  S3. — Class  II,  Division  2,  Subdivision.  Unilaterally  distal  relation  of  lower 
arch.  Left  side  normal;  right  side,  distal.  Normal  lip  pressure  is  bunching  anterior  teeth.  Uni- 
lateral   distoclusion    with    hunching    maxillary    anterior    teeth. 


MALOCCLUSION 


63 


Mesioclusion,  or  Class  III 

Mesioclusion,  or  Class  III,  cases  are  those  that  are  characterized  by 
the  mesial  relation  of  the  lower  arch  to  the  upper  ai'ch  the  width  of 
one  premolar  (Fig.  54).  The  mesio-buccal  cusp  of  the  maxillary  first 
molar  occupies  a  mesio-distal  relation  which  corresponds  to  the  buccal 
embrasure  between  the  mandibular  first  and  second  molars. 

Class  111  presents  a  division  and  subdivision,  which  is  a  bilateral 
mesioclusion  and  a  unilateral  mesioclusion,  and  also  three  types. 

Class  III,  Type  1. — These  cases  present  a  mesial  relation  of  the 
lower  arch  to  the  upper  (Figs.  55  and  56).  The  teetli  in  each  arch 
present    an  even   alignment,   with    practically   no  torsiversion    in   either 


Fig.    54. — Class    III.      Mesial    (anterior)    relation    of    lower   arch.      Mesioclusion. 

arch.  Each  dental  arch  is  very  nearly  the  correct  shape,  and  if 
viewed  separately  from  the  occlusal  view,  the  true  condition  of  the 
malocclusion  would  not  suggest  itself  (Figs.  57  and  58).  There  is  an 
appearance  of  the  lower  arch  having  moved  forward  from  a  normal 
occlusion  to  one  that  is  mesial.  The  lip  pressure  is  normal  and  we 
have  normal  breathing. 

Class  III,  Type  2. — The  lower  arch  is  mesial  to  the  upper  the  width 
of  one  premolar.  The  maxillary  teeth  are  in  good  alignment  with  little 
torsiversion  (Figs.  59  and  60).  The  mandibular  incisors  are  bunched 
and  in  lingual  relation  to  the  upper.    The  patient  is  a  normal  breather 


64 


PRACTICAL    ORTHODONTIA 


with  normal  lip  habits.     This  type  presents  less  facial  deformity  than 
any  of  the  other  types  of  Class  III,  or  mesioelusion,  because  the  man- 


Fig.  55. 


Fig.  56. 

Figs    55   and   56.— Class   III,    Type    1.      Bilaterally   mesial    (anterior)    relation    of   lower   arch    with 
fairly    even    alignment    of    the    maxillary    and    mandibular    teeth.      Bilateral    mesioelusion. 

dibular  anterior  teeth  are  bunched  and  there  is  little  overdevelopment 

of  the  mandible. 


M  ^LOCCLUSION 


c; 


Class  III,  Type  3. — The  lower  arch  is  mesial  to  the  upper  the  width 
of  one  premolar  (Fig.  61).  The  upper  arch  is  underdeveloped  and 
the  anterior  teeth  bunched  and  in  lingual  occlusion  to  the  Lower.  The 
mandibular  teeth  are  in  fairly  good  alignment. 


Fig.  57. 


Fig.  S&. 

Figs     57   and    58. — Class   III.    Tyre    1.      Showing  even   alignment   of   teeth   in   each   arch.      Iiilateral 
mesioclusion  with  even  alignment  of  the  teeth. 

The  facial  deformity  is  very  marked  in  these  cases  owing  to  the  over- 
development of  the  mandible  and  the  underdeveloped  premaxillae. 

Unilateral  Mesioclusion,  or  Class  III,  Subdivision. — These  eases  are 
characterized  by  a  mesial  relation  of  the  arch  on  one  side  and  a  normal 


(it; 


PRACTICAL    ORTHODONTIA 


Fig.  59. 


Fig.  60. 

Figs.   59  and  60. — Class  III,  Type  2.     Bilaterally  mesial   relation  of  lower  arch.      Bilateral   mesio- 
clusion  with  bunched  mandibular  anterior  teeth. 


MALOCCLUSION  67 

relation,  mesio-distal  on  the  other  (Figs.  62,  63  and  64).  The  positions 
of  the  anterior  teeth  may  resemble  any  of  the  types  described  under  the 
division.  Owing  to  one  side  of  the  arch  being  in  normal  mesio-distal 
relation  and  the  other  in  mesial  relation,  there  is  a  tendency  for  a 


Fig.  61. — Class  III,  Type  3.  Bilaterally  mesial  relation  of  lower  arch.  Bunched  maxillary 
anterior  teeth.  Small  upper  arch.  Mandibular  teeth  in  fair  alignment.  Bilateral  mesioclusion 
with   bunched  maxillary  anterior  teeth. 

cross-bite  to  be  present  in  the  region  of  the  incisors,  which  produces 
a  great  amount  of  abrasion  of  the  incisal  edge  of  those  teeth.  Subdi- 
vision cases  of  Class  III  also  cause  an  abnormal  relation  in  the  median 
line  of  the  upper  and  lower  arches. 


68 


PRACTICAL    ORTHODONTIA 


Pig.   I   !. 


Fig.  63. 

Figs.    62    and    63. — Class    III,    Subdivision.       Unilaterally    mesial    relation    of    lower    arch.      Right 
side,  normal;  left  side,  mesial,  unilateral  mesioclusion. 


MALOCCLUSION 


69 


Unilateral  Mesioclusion  and  Distoclusion. — There  are  some  eases 
that  are  mesial  on  one  side  and  distal  on  the  other.  This  type  of  cases 
has  been  incorrectly  called  "Class  IV."  The  ease  shown  (Figs.  65  and 
66)  is  of  that  type.  The  etiologic  factors  are  not  understood  in  regard 
In  these  conditions.  After  a  careful  examination  of  this  case,  the 
author  is  convinced  that  the  trouble  was  entirely  with  the  relation  of 
the  teeth  and  not  with  the  relation  of  the  condyle  to  the  glenoid  fossa. 
There  may  he  some  patients  in  whom  the  mandible  may  he  overde- 
veloped on  one  side,  or  the  condyle  may  occupy  an  anterior  relation  to 
the  glenoid  fossa  on  one  side;  but  it  is  more  probable  that  the  deformity 
is  in  the  arches  and  not  in  the  mandible. 


Fig.   64. — Fronl   view    of  Class    III.    Subdivision,   or  unilateral   mesioclusion. 


Malformation  of  the  Jaws  and  Their  Processes,  and  Abnormal  Relation 
of  the  Mandible  to  the  Maxillae 

In  the  study  of  malocclusions,  we  find  some  conditions  that  can  he 
accurately  described  only  by  taking  into  consideration  the  relation  of 
the  mandible  to  the  face  and  cranium.  We  then  speak  of  those  condi- 
tions as  "malposition  of  the  mandible."  Some  of  these  conditions  in- 
clude an  entire  malposition  of  the  mandible  as  shown  by  the  relation 
of  the  glenoid  fossa  to  the  condyle.  Others  may  he  a  relative  condition 
only,  which  may  be  complicated  by  lack  of  development  in  the  body  of 
the  mandible  that  gives  the  appearance  of  a  misplaced  mandible.  In 
those  cases  where  we  find  an  anterior  position  of  mandible,  Pederspiel 


70 


PRACTICAL    ORTHODONTIA 


Fig..   65.— Unilaterally    mesial    and    dista!    relation    of    lower.    Incorrectly    called    Class    IV       Uni- 
lateral   mesioclusion   and    distoclusion. 


MALOCCLUSION  71 

has  suggested  the  term  mandibular  anteversion.  He  has  also  suggested 
the  term  mandibular  retroversion  for  those  cases  in  which  the  man- 
dible is  distal.  Figs.  67  and  68  show  a  case  taken  from  Lischer's  prac- 
tice which  lie  describes  as  mandibular  retroversion  of  which  the  disto- 


Fig.   66. — Occlusal  view  of  case,  with   lower  arch   unilaterally   mesial  and   distal. 

elusion  is  only  a  symptom.     There  are  cases  on  record  that  show  a  me- 
sial relation  of  condyle  to  the  glenoid  fossa. 

In  considering  the  malformations  of  the  mandible  and  the  maxilla, 
it  is  hard  to  determine  which  is  the  cause  and  which  is  the  effect.    Cer- 


72 


PRACTICAL    ORTHODONTIA 


Fig.   (u '.     Mandibular   retroversion.      The   bilateral   distoclusion   is    nierelj    a   symptom.      (Lisci 


Fig.   C8.      Profile  of  ease   shown   in    Fig.   67.      (I<ischer.) 


M  VLOCCLUSION 


Id 


I'  j.  i  9. — Right  side  of  skull  with   mesioclusion,   or  Class  III;   also  showing  a  malformation   of  the 

mandible. 


Fig.    70. — Left    side    of   skull   with    mesioclusion    and    malformation    of    the    mandible 


74 


PRACTICAL    ORTHODONTIA 


Fig.    71. — Mandibular   curvature.      (Lischer.) 


Fig.  72. — Profile  of  case  shown  in  Fig.  71.     (Lischer.) 


MALOCCLUSION 


75 


F'g.    73-A. — Macromandibular    development.      Note    the    symmetrical,    well-developed    upper    arch; 

the  bilateral  mesioclusion   is   merely   a    symptom    of  the   lower    jaw    deformity.      (Lischer.) 


Fig.  73-B. — Profile    of    case    shown    in    Fig.    73-A.      The    mandible    is    too    long   and    its    angle    too 

obtuse.      (Lischer.) 


(()  PRACTICAL    ORTHODONTIA 

tain  types  of  malocclusion  will  produce  an  overdevelopment  or  an  un- 
derdevelopment of  the  mandible,  while  certain  others  will  have  a 
similar  effect  on  the  maxilla.  However,  in  considering  these  facial  de- 
formities, we  are  compelled  to  recognize  the  malformation  of  the  parts. 
The  close  relation  existing  between  the  malposition  of  the  arches  and 
the  malformation  of  the  jaws  is  shown  in  Pigs.  69  and  70.  it  will  be 
observed  in  this  case  that  the  position  of  the  condyle  is  normal,  as 
nearly  as  it  is  possible  to  determine.  A  greater  malformation  of  the 
mandible  in  a  case  reported  by  Lischer  is  shown  in  Pigs.  71  and  72. 
This  condition  he  lias  termed  mandible  curvature. 

Deformities  of  the  jaws  may  present  themselves  as  developments, 
for  which  the  terms  macro-  and  micro-  serve  admirably.  If  it  is  an  over- 
development of  the  mandible  it  is  called  macromaiidibular.  Such  a 
case  is  shown  in  Fins.  72  and  73.  The  teeth  are  in  mesioclusion  with 
Little  torsiversion  of  either  the  upper  or  the  lower.  The  profile  shows 
the  overdevelopment  of  the  mandible  very  plainly.  We  also  find  cases 
in  which  the  mandible  is  underdeveloped,  which  is  described  as  microman- 
dibular  development.     Pigs.  74  and  75  show  such  a  condition. 

An  overdevelopment  of  the  maxillee  is  termed  macromaxillary  devel- 
opment, while  an  underdeveloped  maxillae  is  a  microm axillary  develop- 
ment. An  extreme  case  of  underdevelopment  of  the  maxilla'  and  there- 
fore micromaxillary  development  is  shown  in  Figs,  7(i  and  77. 

In  considering  the  malrelations  of  the  jaws  and  the  maldevelopment 
of  the  body  of  the  mandible,  the  maxillae,  and  their  processes,  we  must 
be  careful  not  to  confuse  one  with  the  other.  An  overdevelopment  of 
the  mandible  might  be  mistaken  for  a  mandibular  anteversion.  The 
author  is  of  the  opinion  that  the  cases  shown  in  Figs.  69",  70,  72,  and  73 
are  abnormal  developments  of  the  mandible  and  not  mesial  positions 
of  the  condyle.  Care  must  also  be  observed  in  studying  cases  that  present 
an  underdevelopment  of  the  mandible,  so  as  not  to  confuse  them  with 
retroversion  of  the  mandible  which  is  quite  a  rare  condition.  Fig.  78 
shows  a  case  of  distoclusion  with  underdevelopment  of  the  mandible  in 
which  the  condyle  occupies  a  normal  relation  to  the  glenoid  fossa  and  is 
therefore  not  a  case  of  retroversion  of  the  mandible. 

In  the  study  of  the  mesial  and  distal  relations  of  the  lower  arch,  we 
must  use  every  means  at  our  command  to  prove  that  so-called  disto- 
clusions  are  not  mesial  occlusions  of  some  of  the  upper  teeth.  Figs.  33 
and  34  show  cases  in  which  the  upper  molars  have  drifted  forward.  By 
observing  the  malrelation  of  the  approximating  teeth  and  the  arch  re- 
lations ;is  shown  by  the  teeth  thai  are  in  normal  position,  a  correct 
diagnosis  can  be  made.     However,   in  some  eases  a  correct   diagnosis  of 


M  VLOCCLUSION 


Fig.   74. — Micromandibular  develoj  merit.     Note  the   torso-linguoversion   of  the  maxillary  lateral 
incisors,     encroaching    on     the    Cuspid     spaces.       The    maxillary    incisors    are    not    in     labioversion. 

(  Lischer.) 


Fig.    75.  —  Profile    of    case    shown    in    Fig.    74. — The    mandible    is    too    short    in    body    and    rami. 

(Lischer.) 


PRACTICAL   ORTHODONTIA 


Fig.   76. — Micromaxillary   development.      Note  the   marked  arrest   of   development,    complicated   by 
deficiency    in    the    number    of    teeth.       (I_ischer.) 


Fig.   77. — Profile  of  case  shown  in  Fig.  76.     (Lischer.) 


\l  ^LOCCLUSION 


Fig.  78. — "Class  II  skull."     Lower  arch  distal.     Distoclusion. 


Fig.   79. 


Fig. 


Figs.  79  and  80. — Skull  showing  normal  mesio-dista!  relation  of  arches.  Right  side  shown 
in  Fig.  80.  Left  side  of  skull  shown  in  ,  Fig.  '79,  showing  what  appears  to  be  distoclusion  but  is 
a  mesial  relation  of  the  upper  teeth.     (Hellman.) 


80 


PKACTic  \i,  <>ktiioim>\ti  \ 


Fig.    81.-    Occlusal    view    "f    skull    shown    in    Figs.    78   and    7<>.      (Hellman.) 


Fig.    82. — Normal    skull. 


the  conditions  is  more  difficult.  Pig.  79  is  the  left  side  of  a  skull  that 
presents  a  normal  mcsio-distal  relation  of  the  arches.  The  occlusion 
appears  to  have  heen  practically  normal  before  the  teeth  were  lost.  The 
condyle  appears  in  the  normal  position  and  the  mandible  is  also  normal. 
Fig.  80,  the  right  side  of  the  same  skull,  shows  what  may  be  called  a 


MALOCCLUSION  81 

distoclusion  or  a  distal  relation  of  the  lower  arch  on  the  right  side. 
However,  in  examining  the  ocelusional  view  of  the  skull  (Fig.  81),  it 
will  be  observed  that  the  upper  teeth  on  the  right  side  occupy  an  anterior 
position  in  the  skull  as  compared  with  those  on  the  left  side.  By  com- 
paring the  relation  of  the  first  molars  to  the  bases  of  the  zygomatic 
a  relies,  the  difference  in  the  relation  of  the  two  sides  can  he  seen.  Just 
what  would  cause  tins  abnormal  development,  we  have  no  way  of  de- 
termining at  the  present  time  in  this  case. 

In  examining  a  large  number  of  skulls,  the  author  has  found  none 
that  shows  a  distal  relation  of  the  condyle,  although  this  condition  may 
exist.  In  considering  tin1  positions  of  the  condyle,  it  is  well  to  remember 
the  relation  that  exists  between  the  shape  of  the  teeth  and  the  shape  of 
the  condyle  and  glenoid  fossa.  As  a  result  of  malocclusion  and  of  the 
movements  of  the  mandible,  the  shape  of  the  condyle  will  change,  but 
the  change  in  shape  will  always  be  in  keeping  with  the  occlusion  and  be 
limited  by  the  ligaments  that  form  the  temporomandibular  articulation. 
In  studying  the  malpositions  of  the  mandible,  the  anatomy  of  the  parts 
must  he  kept  in  mind  and  the  normal  relation  of  the  condyle  as  shown  in 
Fig.  82. 

In  considering  the  classification  of  malocclusions  in  the  order  of  their 
frequency,  we  find  that  malpositions  of  the  teeth  are  first  in  number, 
then  we  find  malrelations  of  the  arches,  third,  malformations  of  the  jaws 
and  processes,  and  last  in  number  and  frequency  of  occurrence,  malpo- 
sitions of  the  mandible. 

Malocclusion  and  Facial  Deformities 

The  close  relation  between  malocclusion  and  the  development  of  the 
face  must  always  be  considered  in  the  classification.  In  fact,  we  may 
state  that  there  is  an  equally  important  relation  existing  between  normal 
occlusion  and  normal  development  of  the  face.  Various  writers  have 
agreed  that  the  teeth  play  a  greater  part  in  the  production  of  beauty  in 
the  face  than  any  other  organs  or  parts  of  the  face.  It  would  be  very 
difficult  to  conceive  of  a  really  ugly  face  if  the  teeth  were  in  normal 
occlusion,  or  of  a  really  beautiful  face  if  the  teeth  were  in  decided  posi- 
tions of  malocclusion.  However,  there  are  a  great  many  factors  that 
enter  into  the  development  of  the  face,  and  it  is  very  difficult  to  make  a 
set  and  fast  rule  by  which  to  judge  either  facial  deformity  or  facial 
beauty. 

We  must  recognize  in  the  beginning  the  relation  that  the  head  forms 
will  have  on  the  facial  outlines  of  the  patients,  as  well  as  the  influence 


82 


PRACTICAL    ORTHODONTIA 


that  age  will  have  on  the  development  of  the  facial  profile.  The  various 
changes  that  occur  in  the  mandible  as  the  individual  grows  older,  and 
which  are  shown  in  textbooks  as  being  the  result  of  age,  are  familiar  to 
all.     The  evolution  of  the  profile  is  illustrated  in  Fig.  83. 

The  principal  changes  that  are  observed  from  infancy  to   old   age 
are  the  result  of  changes  occurring  in  the  dentition.     In  the  child,  we 


A  B  C 

Fig.   &3. — Evolution   of   tiie    Profile.      (A)    Infancy;    (L!)    Maturity;    (C)    Senility.      (Uscher.) 


Fig.    S4. — Cephalic    Index.       (.!)     Negro,    index',    70,    dolichocephalic;   (B)     European,    Index, 
mesocephalic;    (C)     Samoyed,    index    85,    brachycephalic.       (L,ischer,    after    Tyler.) 


find  the  lower  part  of  the  face  short  until  the  teeth  begin  to  erupt  and 
then  we  notice  the  increase  in  length  that  is  observed  in  the  adult.  With 
the  loss  of  the  teeth,  the  face  again  shortens  and  we  find  the  character- 
istics of  old  age. 

The  shape  of  the  face  will  also  be  influenced  to  a  certain  extent  by 
the  shape  of  the  cranium  and  the  cranium  can  be  classified  according 


MALOCCLUSION  83 

to  a  plan  used  by  anthropologists.  The  cephjdjc_jndcx  is  employed, 
which  is  the  relation  of  the  length  of  the  cranium  from  forehead  to  the 
back  as  compared  with  the  width  on  the  head  between  the  ears.  The 
length  is  made  to  represent  100,  and  the  breadth  is  made  to  represent 
a  fraction  of  that  measurement.  AV hen  the  head  is  broad  there  will  be 
a  tendency  for  the  cranium  to  become  more  rounded,  and  as  a  rule  the 
face  will  also  be  more  rounded  than  in  the  narrow  cranium.  The  cra- 
nium is  classified,  according  to  the  cephalic  index,  when  the  breadth 
across  the  cranium  from  the  cars  is  more  than  eighty  per  cent  of  the 
length  as  the  brachycephalic;  when  the  breadth  is  less  than  seventy-five 
per  cent  of  the  length  it  is  classed  as  dolychocephalic ;  and  when  the 
breadth  is  between  seventy-five  and  eighty  per  cent  of  the  length,  it  is 
termed  mesocephalic  (Fig.  84). 


Pig.   85. 


A  B 

-Facial   Index.      ( A  )    Negro;    (/?)    Caucasian.      (Lischer,   after    Camper.) 


Racial  characteristics  are  also  seen  in  the  study  of  the  facial  profile, 
and  the  various  facial  angles  as  found  in  different  races  are  shown  in 
Fig.  85,  which  is  made  after  the  Dutch  anatomist,  Camper.  By  study- 
ing A  in  Fig.  85  it  will  be  seen  that  the  angle  of  the  mouth  and  nose 
diverges  away  from  a  straight  line,  while  B  approaches  the  straight  line. 

The  projection  of  the  teeth  and  the  lower  part  of  the  face  is  also  in- 
fluenced by  the  race, .and  the  amount  of  that  protrusion  can  be  studied  by 
the  gnathic  index.  The  three  distinct  variations  of  facial  protrusion 
or  projection  of  the  teeth  and  the  lower  part  of  the  face  are  represented 
in  Fig.  86.  Fig.  86A  shows  a  skull  with  a  great  protrusion  of  the  teeth, 
and  is  therefore  termed  prognathic;  Fig.  86S  shows  one  with  less  pro- 
trusion but  still  far  from  a  straight  line,  and  is  termed  mcsognathic; 


si 


l'KACTir  M,    OKTIIODOVN  \ 


while  Fig.  86C  shows  a  face  thai  closely  approaches  the  straight  lines, 
and  is  therefore  termed  orthognathic.  It  must  be  remembered  that  race 
will  influence  the  various  facial  angles,  and  malocclusion  may  cause 
facial   deformities  thai    will   resemble  the   various  conditions  that   have 

I n  mentioned. 

The  facial  characteristics  that  can  be  clearly  seen  in  the  various  races 
can  also  be  followed  to  a  lesser  extent  in  the  different  nations.  It  is  a 
well-known  fact  that  people  of  different  localities  have  facial  develop- 
ments that  distinguish  them  from  people  of  other  localities.  Fig.  87 
shows  various  head  and  face  forms  as  found  in  some  of  the  nations  of 
Europe.     Pig.  88  represents  the  different  facial  characteristics  as  found 


Fig.  86.     Gnathic   [ndex.     (A)    Prognathic;    (B)    Mesognathic;   (C)    Orthognathic.      (  I.isthcr,  after 

Flower.) 


in  some  of  the  blond  and  brunette  races.  Owing  to  the  mixing  of  races 
we  find  the  various  racial  characteristics  blended  together  so  that  it  will 
not  always  be  easy  to  pick  out  the  pure  types.  This  blending  of  races 
and  nations  often  produces  types  that  do  not  resemble  either  of  the  par- 
ents. Consequently  it  becomes  necessary  to  study  each  face  as  a  law 
unto  itself,  and  in  order  to  do  so  it  is  imperative  that  we  have  some  idea 
of  what  constitutes  the  normal.  In  the  first  place,  it  is  very  difficult  to 
define  a  beautiful  face,  as  beauty  is  to  a  certain  extent  a  question  of 
education.  What  one  person  would  consider  beautiful  would  not  be  so 
considered  by  others,  and  this  is  equally  true  in  the  study  of  facial 
forms.     However,  there  are  certain  anatomic  factors  that  enter  into  the 


MALOCCLUSION 


85 


Swiss,    Basle.      Index    64. 


Vamot.      Index    75. 


German,     Baden.       ]i 


Hungarian,    Thorda.      Index    S8.S. 


Lapp,    Scandinavia.      Index    94.  French,    Savoy.      Index    96. 

Fig.    87. — Illustrating    the    relation    between    face-form    and    head-form.       (Lischer,    after    Ripley.) 


86 


PRACTICAL    ORTHODONTIA 


Teutonic    type    (Norway).      Pure   blond. 


Alpine   type    (Austria).      Blue    eyes,    brown    hair.      Index    8i 


Mediterranean  type    (Palermo,   Sicily).     Pure  brunet.     Index   77. 
Fig.   88. — The   three   European   racial    types.      (Lischer,    after    Ripley.) 


MALOCCLUSION 


87 


human  face  which  must  be  considered  and  which  go  toward  the  forma- 
tion of  a  pleasing  whole.  In  studying  a  face,  we  should  do  so  from  at 
least  two  views,  the  front  and  the  profile.  In  some  instances  we  find 
faces  that  present  a  pleasing  outline  if  viewed  from  the  front,  but  when 
viewed  from  the  side,  some  part  is  out  of  harmony  with  some  other  part. 
This  is  often  true  in  the  study  of  conditions  associated  with  malocclusion 
of  the  teeth. 

The  principal  parts  of  the  face  are  shown   in  Fig.  89.     The  mento- 


Fig.  89. — Principal  features  in  the  face,  the  relations  of  which  may  be  altered  by  orthodontic 
treatment.  Front  view.  (a)  Mentolabial  sulcus,  (b)  angle  (angulus  oris),  (c)  upper  lip,  (d) 
cheek  (bucca),  ( e )  nasolabial  sulcus,  (/)  tip  (apex  nasi),  (</)  base  (basis  nasi),  (h)  frontal 
eminence,  (»)  root  radix  nasi.  (/>  dorsum  (dorsum  nasi),  (k)  ala  (ala  nasi),  (/)  nostril 
(nares),    (w)    philtrum,    («)    aperture   (rima  oris),   (o)    lower  lip,    (/>)    chin    (mentum).      (Lischer.) 


labial  sulcus  (a)  is  located  between  the  lower  lip  and  the  chin.  The  de- 
velopment of  this  sulcus  is  greatly  influenced  by  the  position  of  the  roots 
of  the  lower  teeth.  The  angle  of  the  mouth,  angulus  oris  (a),  is  in- 
fluenced by  the  position  of  the  anterior  teeth  and  also  by  the  width  of  the 
arch  in  the  canine  region.  In  cases  of  malocclusion  where  the  arches  are 
narrow  and  the  canines  in  lingual  occlusion,  the  angles  of  the  mouth 
will  be  close  together  and  the  lips  more  or  less  wrinkled.    The  angles  of 


88  PRACTICAL    ORTHODONTIA 

the  mouth  will  also  be  greatly  influenced  by  breathing,  depending  upon 
whether  the  patient  is  a  normal  breather  or  a  mouth-breather.  The  posi- 
tion and  development  of  the  upper  lip  (c)  depends  upon  the  teeth  and 
breathing.  There  are  certain  lip  habits  thai  will  produce  malocclusions, 
and  the  action  of  the  lip  itself  may  produce  its  overdevelopment,  which 
will  cause  an  unpleasing  expression  of  the  face.  The  upper  lip  of  mouth- 
breathers  is  very  shorl  and  thin,  owing  to  the  lack  of  use  that  it  receives 


h- 


(S 


t.  e 

-  ci 

b 


pjg_  90. — Principal  features  of  the  face.  Side  view.  (a)  Mentolabial  sulcus,  (b)  angle 
(angulus  oris),  (c)  upper  lip,  US)  cheek  (bucca),  (c)  nasolabial  sulcus,  (/)  tip  (apex  nasi), 
lg)  base  (basis  nasi;,  tin  trontal  eminence,  (;')  root  (radix  nasi),  (k)  ala  (ala  nasi),  (/) 
nostril  (nares),  (in)  philtrum,  (»)  aperture  (rima  oris),  (o)  lower  lip,  (p)  chin  (mentum). 
(Lischer.) 

in  such  individuals.  The  cheek,  bucca  (d) ,  may  be  influenced  by  the 
amount  of  fat  present  and  exerts  some  pressure  on  the  teeth,  in  turn 
counteracted  by  the  tongue.  In  a  few  cases  the  author  has  seen  the  cheek 
so  full  of  adipose  tissue  that  it  would  exert  sufficient  pressure  on  the 
teeth  to  narrow  the  dental  arches.  The  naso-labial  sulcus  (e)  is  formed 
by  the  junction  of  the  cheek,  the  lip,  and  the  nose.  The  development  of 
this  region  will  be  changed  by  the  abnormal  development  of  any  of  the 
parts  mentioned.    The  canine  looth  also  takes  pari  in  the  development  of 


MALOCCLUSION  89 

the  naso-labial  sulcus,  and  in  individuals  who  have  lost  the  canine  the 
sulcus  becomes  more  noticeable. 

The  development  of  the  tip  of  the  nose  (apex  nasi)  depends  upon  the 
normal  development  of  the  nasal  septum  and  premaxillary  bones,  as  well 
as  of  the  nasal  cartilages.  The  tip  of  the  nose  will  also  be  influenced  by 
mouth-breathing,  and  it  is  exposed  to  all  kinds  of  injuries  resulting  from 
physical  violence,  it  may  be  displaced  and  thus  may  have  an  unpleasing 
effect  on  the  rest  of  the  face.  The  base  of  the  nose  (g)  depends  upon 
nasal  breathing  for  its  proper  development.  In  mouth-breathers  the 
base  of  the  nose  remains  narrow,  the  skin  is  tightly  drawn,  and  we  have 
a  very  unpleasing  appearance.    The  frontal  eminence  is  a  very  noticeable 


Fig.  91. — Facial   cast   of  boy   nine  years   of  age.   with   normal   occlusion.      (Parsons.) 

part  of  the  face  but  is  not  influenced  by  the  teeth.  It  may,  however,  be 
taken  as  an  indication  as  to  what  the  development  of  the  face  should  have 
been  in  those  patients  who  have  decided  malformations  of  the  teeth  and 
jaws.  The  root  of  the  nose  (i),  located  at  the  base  of  the  frontal  bone, 
depends  for  its  development  upon  normal  breathing,  and  also  upon  the 
proper  development  of  the  frontal  sinus  with  which  it  is  closely  asso- 
ciated. The  dorsum  of  the  nose  ( ./' )  may  present  a  variety  of  shapes, 
ranging  from  pug  to  Roman,  and  may  also  be  influenced  by  racial  char- 
acteristics. Like  the  tip  of  the  nose,  it  is  subject  to  injury,  which  may 
change  its  shape.  Abnormal  developments  that  influence  the  develop- 
ment of  the  septum  will  also  play  some  pari  in  shaping  the  dorsum  of  the 


90 


PRACTICAL    ORTHODONTIA 


Qose.  The  ala  nasi,  or  ala,  of  the  nose  (/>')  is  largely  influenced  by  en- 
vironment. In  persons  who  have  been  mouth-breathers  we  find  that  the 
ala  is  qoI  developed  normally,  and  il  remains  thin  and  flabby.  This  thin- 
ness and  ftabbiness  of  the  ala  has  been  th'oughl  l>y  some  to  be  a  contribut- 
ing factor  toward  continued  mouth-breathing,  owing  to  the  fad  that  the 
ala  is  not  sufficiently  developed  to  prevent  the  atmospheric  pressure  from 
shutting  off  flic  nasal  tract.  In  normal  breathers  the  ala  is  well  devel- 
oped and  gives  a  strong  expression  to  the  face.  The  nostril  (I)  depends 
upon  the  development  of  the  surrounding  parts  for  its  shape.  The  phil- 
trinn  (ii)  plays  ;i  great  part  in  the  beauty  of  the  face  and  is  dependent 
upon  the  position  of  the  teeth  for  its  shape.  The  development  of  the 
nose,  the  development  of  the  lips,  and  in  fact  the  development  of  all  of 
the  parts  around  the  oral  cavity  will  influence  the  philtrum.  The  aper- 
ture of  the  mouth   ( ii  )   will  he  of  ;i  size  and  shape  in  keeping  with  the 


Fig.   92. — Models  showing  the   occlusion   of  the   teeth   of   Fig.   91.      (Parsons.) 

lips.  In  some  individuals  we  find  an  aperture  that  is  quite  small  and  the 
dental  arches  large,  while  in  others  the  reverse  may  be  true.  The  lower 
lip  (o)  is  a  great  factor  in  the  beauty  of  the  face.  No  part  of  the  face 
adds  so  much  to  the  expression  as  do  the  lips,  and  the  lower  lip  is  equally 
as  important  as  the  upper.  In  fact,  in  some  respects  the  lower  lip  is 
more  of  a  factor  in  producing  malocclusion  of  the  teeth  than  is  the  upper. 
In  lip  ha  hits,  we  find  that  the  lower  lip  is  the  one  that  does  the  most 
harm.  Month-breathers,  as  a  rule,  have  thick  lower  lips,  which  are  held 
between  the  hrwer  and  the  upper  anterior  teeth,  with  the  result  that  the 
maxillary  anterior  teeth  are  forced  outward.  In  mesioclusion  cases,  the 
lower  lips  play  a  great  part  in  forcing  the  mandibular  incisors  lingually 
if  the  patient  is  a  normal  breather.  The  lower  lip  covers  the  mandibular 
anterior  teeth  and  overlaps  the  incisal  third  of  the  maxillary  incisors, 


MALOCCLUSION  91 

therefore  exerting  a  direct  pressure  on  the  labial  surfaces  of  the  upper 
teeth  in  the  normal  breather.  The  chin  (p)  has  long  been  recognized  as 
an  important  factor  in  the  development  of  the  face,  and  people  have  been 
classified  according  to  the  development  of  the  chin  as  having  strong  or 
weak  characters.  As  the  chin  is  the  anterior  part  of  the  mandible  it  will 
be  more  or  less  affected  by  everything  that  affects  the  mandible.  In 
cases  of  distoclusion  with  mouth-breathing,  the  chin  is  greatly  under- 
developed, while  in  cases  of  mesioclusion  the  chin  will  be  overdeveloped. 
In  unilateral  cases  of  malocclusion,  in  cases  in  which  there  is  an  unequal 
development  of  the  two  sides  of  the  mandible,  we  find  that  the  chin  may 
be  deflected  to  one  side  or  the  other.    In  cases  of  neutroclusion,  charac- 


£«*«£' 


-J 


Fig.   93. — Normal  type   of   face   with   normal   occlusion.      (Lischer.) 

terized  by  underdevelopment  of  the  dental  arch,  the  chin  will  suffer  in 
development  because  the  mandible  will  be  small. 

Fig.  90  shows  a  profile  of  the  face  with  the  same  anatomical  mark- 
ings as  are  found  in  the  front  view  of  Fig.  89.  This  profile,  as  well  as 
the  front  view,  probably  gives  the  artist's  conception  of  what  he  con- 
siders a  normal  face  should  be.  The  two  views  also  show  the  necessity  of 
having  both  a  front  and  a  side  view  of  each  patient.  The  front  view  is 
a  very  good  face  and  shows  each  of  the  parts  normally  developed.  Some 
might  object  to  the  size  of  the  mouth,  but  from  an  anatomic  standpoint 
the  author  considers  that  the  mouth  is  of  the  proper  size  and  that  the 
face  is  nearly  normal.  The  profile  view,  from  an  anatomic  standpoint, 
is  not  as  good,  as  the  lower  part  of  the  face  is  too  weak.  The  mandible, 
the  chin,  and  the  lower  lip  are  too  receding  for  a  face  that  has  a  normal 


92  PRACTICAL    ORTHODONTIA 

set  of  teeth,  and  if  the  teeth  are  receiving  proper  use.  and  the  subject 
has  normal  breathing.  However,  Fig.  90  only  shows  how  difficult  it  is  to 
select  a  definite  type  of  beauty  or  of  face  to  please  everyone. 

It  is  equally  as  difficult  to  decide  just  what  the  normal  face  is,  for 
we  have  shown  that  racial  characteristics  enter  into  the  question  to  such 
an  extent  that  we  are  unable  to  choose  a  standard  type.  It  is  conceded 
that  the  best  balanced  faces  are  those  that  have  all  of  the  teeth  present 
and  the  teeth  in  normal  occlusion.  However,  in  examining  people  with 
normal  occlusions  we  find  that  the  faces  differ  in  varying  degrees  ami 
that  all  are  not  equally  beautiful. 

"What  might  be  considered  beautiful  by  one  person  would  not  be  so 
considered  by  another.    The  African  negro  is  probably  considered  beau- 


Fig.    94. — Prominent    chin,    with    normal    denture.      (Lischer.) 

tiful  among  his  own  people,  but  he  would  not  satisfy  the  sense  of  the 
beautiful  in  the  European.  Also  certain  developments  that  are  in  har- 
mony in  one  face  would  be  out  of  harmony  in  another.  Some  faces  are 
in  balance  with  pug  noses,  other  faces  look  well  with  Roman  noses,  but 
to  reverse  the  noses  on  the  respective  faces  would  lie  to  create  \*'vy  un- 
pleasing  facial  expressions. 

In  order  to  arrive  at  any  conception  of  what  a  face  should  be,  it  is 
necessary  to  study  a  large  number  of  faces  of  various  types.  Fig.  !M 
shows  the  facial  cast  of  a  hoy  of  nine,  which  may  be  considered  to  he 
nearly  normal.  The  forehead,  the  nose,  the  lips,  and  the  chin,  all  show 
that  the  boy  is  a  normal  breather  and  in  order  to  have  the  development 
of  the  face  that  he  has,  he  must  possess  a  nearly  normal  occlusion  of  the 


MALOCCLUSION  93 

teeth.  The  occlusion  of  the  teeth  is  shown  in  Fig.  92.  In  comparing  this 
face  with  the  one  shown  in  Pig.  90,  the  author  prefers  the  face  of  the  boy 
to  the  artist's  conception,  since  his  idea  of  a  normal  face  is  based  on  the 
anatomic  parts  that  as  a  whole  go  to  make  up  the  face.  Some  of  us 
might  claim  that  the  mouth  and  lower  part  of  the  face  in  Pig.  91  is  too 
heavy,  but  it  must  be  remembered  that  a  hoy  at  the  age  of  nine  has  his 
permanent  incisors,  that  the  arches  should  be  wide,  and  that  the  mouth 
should  be  full. 

Angle  has  stated  that  the  best  harmony  and  the  best  balance  of  the 
face  will  be  found  in  those  individuals  who  have  normal  occlusion  of 
the  teeth.  The  author  believes  this  to  be  true,  but  it  does  not  prove 
that   all    individuals   with    normal    occlusions   will    look    alike.      Fig.    93 


Fig.  95.      Receding  chin,   with   normal   denture.      (Lischer.) 

shows  another  type  of  face  that  has  normal  occlusion  of  the  teeth.  It 
will  be  observed  that  this  type  of  fact'  closely  approaches  the  type  shown 
in  Fig.  91. 

Fig.  94  shows  a  type  of  face  thai  possesses  a  prominent  dun  and  nor- 
mal occlusion  of  the  teeth.  The  development  of  the  chin  and  mandible 
in  this  type  of  face  is.  in  the  author's  opinion,  the  result  of  use.  We 
find  this  type  of  chin  in  individuals  who  are  public  speakers,  actors, 
lawyers,  and  others  who  have  used  the  muscles  of  speech  to  a  great  ex- 
tent. In  fact,  it  has  been  said  by  anatomists  that  the  development  of 
the  chin  in  man  has  been  the  result  of  speech.  The  observation  of  the 
author  is  in  keeping  with  this  statement,  and  the  type  of  face  shown  in 
Pig.  94  is  such  as  is  found  in  those  who  are  normal  breathers  and  also 


94 


I'KACTICAL    ORTHODONTIA 


public  speakers.  It  would  be  impossible  to  have  the  development  of  the 
chin  in  the  extenl  as  shown  in  an  individual  who  is  a  mouth-breather. 
The  use  of  the  teeth  as  organs  of  mastication  has  also  played  a  part  in 
the  formation  of  the  face  shown  in  Fig.  94. 

Pig.  95  illustrates  the  type  of  face  with  a  receding  or  weak  chin,  but 
which  has  a  normal  occlusion.  Willi  these  individuals,  the  teeth  are  in 
normal  positions  but  the  functions  of  the  teeth  have  been  neglected  to 
such  an  extent  that  the  supporting  structures  have  never  developed. 
These  patients  are  normal  breathers,  and  the  maxillae  have  developed 


A.  B. 

Fig.   96. — Photographs   of    12   year   "I<1    patient    before   treatment.    (Tanzey.) 


enough  so  that  normal  breathing  is  possible.  The  mandible  and  chin 
have  not  developed  because  of  the  lack  of  use  in  mastication,  and  the 
muscles  of  speech  have  also  been  inactive.  People  of  this  type  are  not 
forcible  speakers,  for  if  they  were  the  chin  would  develop  to  the  proper 
size.  The  lack  of  proper  development  is  seen  in  the  mentodabial  sulcus 
and  the  mental  eminence.  The  normal  occlusion  of  the  teeth  and  the 
normal  respiration  give  the  upper  and  lower  lip  a  good  expression,  but 
the  weakness  is  in  the  mandible  and  chin. 

In  studying  facial  development  associated  with  malocclusion,  we  find 


MALOCCLUSION  95 

• 

that  certain  types  of  malocclusion  always  give  certain  types  of  facial  de- 
formity. With  a  certain  malocclusion,  there  is  always  a  certain  action 
of  the  muscles,  a  certain  manner  of  breathing  and  a  certain  action  of  the 
teeth  in  mastication,  so  that  the  facial  development  associated  with  mal- 
occlusion is  always  easily  understood  and  recognized.  In  other  words, 
if  given  a  model  of  a  case  of  malocclusion,  it  is  possible  in  a  great  number 
of  cases  to  describe  or  draw  the  type  of  face  that  the  patient  possesses. 
Cases  of  neutroclusion,  with  underdevelopment  of  the  arches,  always 
show  a  lack  of  development  in  the  anterior  part  of  the  face.  There  is  a 
pinched  expression  around  the  mouth,  too  short  a  distance  between  the 
corners  of  the  mouth,  and  the  lips  present  a  wrinkled  appearance  as  if 


Fig.   97. — Type    of    malocclusion    present    in    Fig.    96. 

there  was  too  much  material  in  the  lips  and  they  were  wrinkling.  The 
a  he  of  the  nose  are  more  or  less  underdeveloped,  are  too  close  together, 
and  the  mouth  seems  too  small  for  the  faee.  This,  in  brief,  is  the  facial 
expression  if  the  patient  is  a  normal  breather.  Such  a  type  is  shown 
in  Fig.  9'6.  Note  the  pinched  expression  of  the  lips  and  mouth,  and  this 
is  what  is  always  found  in  this  type  of  malocclusion  as  shown  in  Fig.  97. 
We  find  a  characteristic  facial  deformity  in  those  patients  who  are 
mouth-breathers  and  who  still  have  a  normal  mesio-distal  relation  of 
the  arches.  Such  a  face  is  shown  in  Figs.  98  and  99.  The  short  upper 
lip  is  characteristic,  the  lower  lip  is  often  tucked  in  and  rests  against 
the  lower  teeth,  and  owing  to  the  fact  that  the  pressure  of  the  tongue 
is  abnormal,  or  rather  absent,  the  lower  teeth  are  forced  lingually  by 
the  action  on  the  lower  lip.  The  edges  of  the  upper  incisors  rest  against 
the  lower  lip,  and  they  are  forced  labially.     The  mandible  and  chin  may 


96 


PRACTIC  \l.    ORTHODONTIA 


be  underdeveloped.  The  cusps  of  the  teeth  are  generally  long  and  well 
developed,  which  accounts  for  the  fact  that  the  arches  are  in  normal 
mesio-distal  relation  when  the  patient  is  a  mouth-breather. 


Fig.   98.  Fig.  99. 

Figs.  98  and  99.— Facia]  casts  of  patienl   with  neutroclusion,  who  was  mouth-breather.      (Parsons.) 


Fig.    100. — Models    of    patient    shown    in    Figs.    98    and    99.      Neutroclusion.      Patient    was    mouth- 
breather,   with  abnormal   lip  action.      (Parsons.) 

The  facial  deformities  that  are  present  in  neutroclusion  are  very 
similar,  but  the  development  of  the  lips  may  be  different  and  will 
change  the  facial  type  to  a  certain  extent.     Fig.   101  shows  the  facial 


MALOCCLUSION 


97 


development  of  a  boy  ten  years  of  age.  The  upper  lip  is  not  func- 
tionating- as  it  should  and  does  not  meet  the  lower  lip,  as  a  result  of 
which  the  mouth  is  open  and  the  face  has  the  so-called  idiotic  stare. 
The  lower  lip  is  also  abnormal  in  action  and  falls  away  from  the  upper 
teeth.  The  lower  lip  when  occupying  its  proper  position  should  cover 
the  lower  teeth  and  part  of  the  upper  teeth.  It  will  be  observed  that 
the  upper  and  the  lower  lips  are  thickened,  and  associated  with  this  type 
of  thick  lips  is  an  abnormal  action  of  the  glands  of  the  lips.  The  saliva 
is  viscid  and  stringy.     The  mucous  glands  of  the  lips  are  often  closed 


Fig.   101.— Showing 


ips  du 


Lischer.) 


and  abnormal,  which  accounts  for  the  thickness  of  both  the  upper  and 
the  lower  lips.  If  the  lips  were  used  properly,  the  action  would  have  a 
beneficial  result  on  the  mucous  glands,  and  the  lips  would  become  thin- 
ner. The  facial  expression  of  this  patient  is  made  more  objectionable  by 
the  spacing  of  the  upper  teeth,  which  in  this  type  of  lips  is  generally 
the  result  of  abnormal  frenum.  Observe  in  this  case  that  the  lower  lip 
does  not  rest  against  the  upper  teeth  as  in  Fig.  102.  This  face  shows 
an  abnormal  development  of  the  lips,  which  may  be  found  in  cases  of 
neutroclusion  with  labioversion  of  the  anterior  teeth  or  may  be  present 
in  distoclusion  cases.  Such  lips  are  characteristic  of  mouth-breathers 
who  have  a  comparatively  normal  action  of  the  mucous  glands  and  are 


08 


K'Acric  \i.  oktiiooonti  \ 


therefore  qo1  thiekened  ;is  is  seen  in  Pig.  L01.  In  Pig.  L02,  the  Lower  lip 
lies  in  cdiitact  with  the  upper  teeth,  which  accounts  dor  some  of  the  pro- 
trusion of  the  upper  teeth.  As  the  upper  lip  is  short  it  exerts  no  re- 
straining influence  on  the  upper  teeth,  which  arc  forced  outward  by  the 
lower  lip.  The  irritation  of  the  Lower  lip  against  the  upper  teeth  has 
been  responsible  for  the  thickening  of  the  lip,  which  cause  is  different 
from  that  which  produces  the  condition  in  Fig.  101. 

Certain  types  of  malocclusion  are  sure  to  produce  certain  facial  de- 
formities. In  cases  of  neutroclusion  with  linguoversion  of  the  maxillarj 
incisors   (Class  I  cases  with  the  upper  incisors  in  lingual  relation  to 


■> 


4    *N 


Pig.    102.-   Shows   malformation   of   the   lips;    1 1 < > 1 1-  especially   the   extreme   deficiency    of   tin-    upper 
lip;    female    13    years    old.      (L,ischerJ 

the  Lowers),  as  shown  in  Fig.  LOS,  we  find  that  the  lower  lip  is  very 
prominent  and  that  the  upper  lip  is  underdeveloped  because  of  the 
lingual  relation  of  the  maxillary  anterior  teeth.  The  facial  development 
is  shown  in  Fig.  104.  These  cases  very  much  resemble  mesioclusion, 
or  (lass  III,  cases,  and  this  is  still  more  true  when  the  maxillary  incisors 
are  in  such  a  position  that  the  patient  can  not  close  the  jaw  and  make 
the  molars  occlude  without  allowing  the  mandible  to  be  pushed  for- 
ward. The  author  has  seen  cases  of  this  type  where,  if  the  patient 
closed  the  jaws  naturally,  the  maxillary  and  mandibular  incisors  would 
occlude  edge  to  edge.     It  was  impossible  for  the  patient  to  retract  the 


MALOCCLUSION 


99 


Mg.    103. — Neutroclusion    complicated    by    linguoversion    of    the    maxillary    incisors,    nge    eleven. 

(  L,ischer.  ) 


Fig.   104. — Facial  deformity  of  case  shown  in  Fig.   103.     (Lischer.) 


100 


PRACTICAL    ORTHODONTIA 


mandible  sufficiently  to  bring  the  lower  incisors  behind  the  maxillary  in- 
cisors which  therefore  made  it  necessary  for  the  patient  to  protrude 
the  mandible  in  order  that  the  molars  might  be  brought  together.  As 
a  result  of  this,  the  mandible  would  be  protruded,  which  would  pro- 
duce a  condition  similar  to  anteversion  of  the  mandible.  Of  course,  the 
forward  movement  of  the  mandible  is  only  for  the  purpose  of  mastica- 
tion, and  at  least  in  a  number  of  cases  seen  by  the  author,  there  had  not 
been  any  change  in  the  temporo-mandibular  articulation  that  would 
keep  the  mandible  forward.  The  facial  deformity  in  such  a  case  is 
shown  in  Fig.  105.     Notice  the  heavy  appearance  of  the  lower  part  of 


:• 

■ 

^ 

4 

«^ 

A.  B. 

Fig.    105. — Neutroclusion,    or    Class    I.    with    lingual    relation    of    the    maxillary    incisors    to    lower. 


the  face,  the  prominent  chin,  the  thick  lower  Lip,  and  the  greater  full- 
ness of  the  upper  lip  that  is  seen  in  Fig.  104.  The  difference  in  the  ap- 
pearance of  the  upper  lip  in  the  faces  as  shown  in  Figs.  104  and  105  is 
that  in  Fig.  104  there  is  more  linguoversion  or  lingual  position  of  the 
maxillary  incisors  than  there  is  in  Fig.  105.  In  Fig.  105,  the  maxillary 
incisors  are  lingual  slightly,  but  not  enough  but  that  it  is  necessary  for 
the  patient  to  protrude  the  mandible  when  the  molars  are  brought  to- 
gether. 

In  those  cases  of  neutroclusion  complicated  by  linguoversion  of  the 
maxillary  and  mandibular  anterior  teeth  (Class  1  with  bunched  anterior 
teeth),  we  have  a  facial  deformity  that  consists  of  a  lack  of  development 


MALOCCLUSION  101 

around  the  lips  (Figs.  106  and  107).  These  patients  may  he  normal 
breathers,  as  was  the  patient  from  which  Fig.  107  was  made.  The  action 
of  the  lips  is  normal,  but  owing  to  the  lack  of  development  in  the  incisal 
regions  of  the  upper  and  lower  arch,  the  lips  are  sunken,  they  have  not  the 
proper  contour,  and  a  similar  appearance  exists  as  is  found  upon  the  ex- 
traction of  some  of  the  anterior  teeth. 


Fig.     106. — Neutroclusion     complicated     by     linguoversion     of     the     anterior     teeth,     aye     twelve. 

(Lischer.) 

Neutroclusion,  or  Class  I.  cases  present  many  combinations  of  mal- 
occlusion of  the  anterior  teeth,  and  as  a  result  of  which  we  find  an  al- 
most endless  variety  of  facial  deformities.  A  rather  common  condition 
of  the  teeth  is  shown  in  Fig.  108,  in  which  Vve  have  a  normal  mesio-distal 
relation  of  the  arches  with  infraversion  or  lack  of  occlusion  of  the  upper 
anterior  teeth.    These  cases  mar  he  the  result  of  abnormal  habits  of  the 


102 


PRACTICAL    ORTHODONTIA 


Fig.    107.     Facial  deformity  of  case  shown   in   Fig.   106.     (Lischer.) 


Fig.    108.— Neutroclusion    complicated    by    infraversion    of    the    anterior    teeth,    age    sixteen. 

i  L,ischer  i 


MALOCCLUSION 


103 


tongue  or  lips;  they  may  be  the  result  of  the  elongation  of  the  molars  at 
the  time  of  the  eruption  of  the  second  molars ;  or  they  may  he  associated 
with  deformities  of  the  maxilla  and  mandible  as  the  result  of  rickets, 
and  there  may  be  some  glandular  disturbance  of  the  ductless  glands. 
Whatever  the  etiologic  factors  are,  the  facial  deformity  is  always  well 
marked  and  is  similar  to  that  shown  in  Fig.  109. 

In  neutroclusion,  or  Class  I  eases,  and  when  the  patients  are  mouth- 
breathers,  we  find  abnormal  action  of  the  lips,  protruding  maxillary 
anterior  teeth,  an  underdeveloped  chin,  a  narrow  upper  arch  and  lack 


Fig.     109. — Facial    deformity    of    neutroclusion     complicated    by     infraversion     of    anterior    teeth. 

( I.ischer.) 


of  development  of  the  nose — all  of  which  has  an  unpleasing  influence 
upon  the  face  (Fig.  110). 

To  one  familiar  with  the  effects  of  malocclusion  upon  the  face,  it 
would  be  easy  to  conceive  of  the  malocclusion  present  with  the  facial 
deformity  as  shown  in  Pig.  110.  The  abnormal  action  of  the  lips  has 
had  an  influence  upon  the  teeth  until  at  the  present  time  the  malocclu- 
sion is  so  great  that  the  lips  cannot  be  closed  over  the  teeth,  which 
will  allow  the  malocclusion  to  become  more  pronounced.  The  lack  of  nor- 
mal action  of  the  muscles  of  mastication  and  the  resulting  lack  of  use  has 
allowed  the  mandible  to  remain  underdeveloped.  The  upper  arch  is  nar- 
row. ;is  is  also  the  nasal  cavity  in  these  c;ises  (Fig.  Ill  i. 


104 


PRACTICAL    ORTHODONTIA 


Another  type  of  facial  deformity  that  is  not  found  as  often  as  those 
that  have  been  mentioned  is  shown  in  Fig.  112.  These  cases  call  for 
xvvy  careful  study  in  regard  to  etiology  and  treatment.  The  mal- 
occlusion consists  of  a  prominence  of  the  maxillary  and  mandibular 
teeth,  which  is  generally  associated  with  narrow  arches.  Early  lack  of 
development  of  the  osseous  systems  and  lack  of  development  of  the 
mandible  and  maxillas  have  played  a  part  in  the  lack  of  development 
of  the  face. 

In  considering  facial  deformities  as  related  to  malocclusion,  we  have 


Fig.    110. — Facial    deformity    of    case    shown    in    Fig.    111.       (Lischer.) 


so  far  only  spoken  of  those  cases  that  have  ;i  normal  mesio-distal  re- 
lation of  the  arches.  It  is  to  be  expected  that  as  soon  as  we  come  to 
those  cases  that  have  abnormal  relations  of  the  arches  that  the  condi- 
tions will  become  more  marked  and  the  facial  deformities  greater. 
Fig.  113  shows  a  decided  facial  deformity,  protruding  upper  anterior 
teeth,  short  thick  upper  lip,  and  a  thick  lower  lip.  Mouth-breathing 
is  present,  which  accounts  for  most  of  the  facial  deformity.  The  mal- 
occlusion associated  with  the  facial  deformity  shown  in  Fig.  113  is 
shown  in  Fig.  114.  The  distal  relation  of  the  lower  arch  can  be  readily 
seen,  and  the  protruding  upper  incisors  that  are  the  result  of  abnormal 


MAUH'CI.rslOX 


105 


lip  action  are  very  apparent.  The  lower  lip  has  pushed  the  upper 
teeth  outward,  causing  spaces  between  all  of  them.  The  extreme  de- 
formity in  this  ease  has  been  the  result  of  abnormal  action  of  the  lips, 
and  not  so  much  the  result  of  the  distal  relation  of  the  lower  arch. 
In  proof  of  this  Fig.  115  shows  another  case  of  distal  relation  of  the 
lower  arch,  and  the  distal  relation  is  as  great  as  it  is  in  the  previous 
case.     By  comparing  Pig.  11.1  with  Pig.   114  it  will  In-  seen  that  each 


Fig.    111. — Neutroclusion   complicated   by   lalnoversion   of   the   upper   incisors,   female,   age    sixteen. 

( Lischer.) 


lower  arch  is  equally  distal.  The  difference  in  the  facial  outlines,  as 
well  as  the  different  actions  of  the  lips,  can  he  seen  by  comparing  Fig. 
116  with  Fig.  113.  The  facial  deformity  present  in  the  distal  relation 
of  the  lower  arch  is  very  much  the  same,  and  differs  only  as  the  action 
of  the  muscles  differs,  and  as  to  whether  the  patient  is  a  normal  or  an 
abnormal  breather.  In  those  patients  who  are  able  to  close  the  lips 
and  breathe  through  the  nose,  we  find  that  the  upper  lip  is  longer  and 
that  the  chin  is  better  developed  as  a  result  of  the  normal  breathing  and 


106 


PRACTICAL    OKTIIODONTIA 


normal  lip  action.  The  greatest  deformity  is  lack  of  development  in  the 
region  of  the  mandibular  incisors,  which  results  in  an  abnormal  mento- 
labial  sulcus.    Such  a  facial  deformity  is  shown  in  Fig.  117. 

Lischer  shows  a  facial  deformity  that  is  due  to  a  "malposition  of 
the  mandible;  the  distoclusion  of  the  lower  arch  is  merely  a  symp- 
tom." This  is  shown  in  Fig.  118.  It  will  lie  noticed  that  the  lips  arc 
closed,  which  indicates  that  the  patient  is  at  least  able  to  breathe 
through  1  lie  nose  pari  of  the  time.  The  chin  is  better  developed 
than  the  chin  of  the  patient  shown  in  Fig.  117. 

Patients  suffering  from  distoclusions  or  distal   relation   of  the  lower 


Fig.     112. — Facial     type     of     neutroclusion    complicated     by     labioversion     of     the     maxillary     and 
mandibular  anterior   teeth.      (Lischer.) 


arch  soon  become  cognizant  of  their  facial  deformity  and  often  try  to 
conceal  it  by  holding  the  mandible  in  a  false  position. 

The  malocclusion  in  Fig.  119  is  a  case  of  complete  distal  relation 
of  the  lower  arch,  with  some  protrusion  of  the  maxillary  anterior  teeth. 
The  result  of  the  malocclusion  upon  the  facial  lines  is  shown  in  Figs. 
L20  and  121.  The  underdevelopment  of  the  mandible  is  very  notice- 
able, as  is  the  receding  upper  lip.  In  fact,  the  entire  lower  part  of 
the  face  is  greatly  underdeveloped,  and  the  face  has  the  appearance 
of  distoversion  of  the  mandible  or  a  distal  relation  of  the  mandible. 
There  is  no  direct  evidence  to  prove  that  the  mandible  is  any  farther 


MALOCCLUSION 


107 


Fig.    113. — Showing   adenoid   appearance.      (Duckworth.) 


Fig.   114.  —  Showing  abnormal   relation   of  molars  and  extreme  protrusion   of  the  maxillary  incisors 

(Duckworth.) 


108 


PRACTICAL    ORTHODOX'!' I  \ 


Fig.    115. — Distoclusion    with   labioversion    of   maxillary    incisors.       (Barr.) 


Fig.    116. — Facial   development    of    ease    shown    in    Fig.    115.       (Barr.) 


MALOCCLUSION 


109 


distal  than  it  should  be,  but  the  chin  is  greatly  receding  regardless  of 
the  position  of  the  mandible.  The  patient  early  recognized  the  facial 
deformity  and  acquired  the  habit  of  holding  the  mandible  forward 
as  is  shown  in  Figs.  122  and  123.  This  position  was  the  position  of  the 
mandible  while  speaking  and  during  all  of  the  hours  of  the  day  ex- 
cept when  masticating.  The  effect  on  the  facial  lines  by  changing 
the  position  of  the  mandible  can  be  readily  seen  by  comparing  Figs. 
120  and  121  with  Figs.  122  and  123. 

The  facial  deformity  accompanying  mesioclusion,  or  Class  III,  cases 
is  very  well  understood.     It  is  one  of  the  facial  deformities  with  which 


Fig.  117. — Shows  malrelation  of  the  lower  lip  to  the  upper,  and  abnormal  mento-labial  sulcus,  due 
to  distal   relation   of  the  lower  arch;   male    14  years  old.      (Lischer.) 


the  public  lias  been  familiar  for  some  time.  The  overdevelopment  of 
the  mandible  that  accompanies  these  cases  has  been  described  by  various 
names  and  has  been  thought  to  be  the  result  of  a  great  many  condi- 
tions that  have  played  no  influence  on  it  whatever.  The  facial  de- 
formity is  very  similar  in  all  of  these  cases,  the  principal  differences 
being  in  the  extent  of  the  overdevelopment  of  the  mandible  and  in  the 
variation  in  the  angle  of  the  ramus.  Fig.  124  shows  what  may  be  con- 
sidered a  typical  case  of  such  a  deformity.  Another  similar  condition 
is  shown  in  Fig.  125.  A  greater  number  of  these  conditions  could  be 
shown,  but  thev  are  so  similar  that  it  would  only  be  more  or  less  a 


I  II)  PRACTIC  VL    0RTH0D0NT1  \ 

repetition.     Other  cases  of  this  type  can   be   found   in  the  chapter  on 
Classification  and  Treatment. 

Facial  deformities  accompanying  maldevelopmenf  of  the  parts  are 
often  more  noticeable  than  those  that  have  resulted  from  malocclu- 
sion. Ankylosis  of  the  mandible,  which  may  be  the  result  of  accident 
or  disease,  by  limiting  the  movement  of  the  mandible  contributes  to 
the  underdevelopment  of  the  same.  Such  a  condition  is  shown  in  Fig. 
126.  It  has  long  been  known  that  use  has  played  a  great  part  in  the 
development  of  the  mandible,  and  that  lack  of  use  has  had  the  oppo- 
site result.     This  is  shown  in  the  above  ease.     The  effect  of  use  when 


Fig.    118.— Deformit}    due   to   malposition   of  the   mandible;   the  distoclusion   of   the   lower  arch   is 
merely  a   symptom;   male    11   years  old.      (Lischer.) 

there  is  a  unilateral  limitation  of  movement  is  shown  in  Fig.  127 
causing  a  very  unpleasing  unilateral  facial  development. 

Abnormal  congenital  development  of  the  maxilla  and  mandible  pro- 
duces a  number  of  facial  deformities,  harelip  and  cleft  palate  being 
the  most  common.  The  entire  absence  of  the  mandible  has  been  re- 
ported by  some  writers.  A  case  of  extreme  facial  deformity  shown 
by  Blair  is  reproduced  in  Fig.  128. 

Malocclusions  therefore  produce  so  many  different  facial  deformi- 
ties, that  it  is  only  to  be  expected  that  a  great  many  people  who  seek 
the  services  of  an   orthodontist,  do  so  with   a   view  of  having  the  ap- 


M  VLOCCLUSION 


111 


Pig.    110. — Distoclusion,    or   Class    II.      (Parsons.) 


Fig.    120.  Fig.    121. 

Figs.    120   ami    121. —  Facial    views   of   patient    with    mandible    in    masticating    position.      <  Parsons.) 


Fig.    122. 


Fig.    123. 


Figs.    122   and    123. — Mandible    protruding   to    overcome    facial    deformity    present,    and    shown    in 
Figs.    120    and    121.      (Tarsons.) 


112 


PRACTICAL    ORTHODONTIA 


Fig.    124. — Mesioclusion,   or  Class  III,   with  macromandibular  development.      (Fernald.) 


Fig.   125. — Facial  deformity  in  mesioclusion,  or  Class  III,  case.     (Parsons.) 


MALOCCLUSION 


IK 


Fig.    126. — Facial  deformity  due   to   close  ankylosis  at   5   years,   which   resulted   from   an   injury  at 

3   years.      (  Blair.) 


Fig.    127. — Facial     deformity     produced     by     lack     of     use.     (Blair.) 


pearance  of  the  face  improved.    As  a  diagnostic  aid,  Lischer  has  made 
several  suggestions,  which  are  here  shown. 

In  neutroclusion  cases,  in  which  we  have  a  lack  of  development  of 
the  alveolar  process  with  a  greatly  crowded  condition  of  the  teeth,  by 
placing  wax  under  the  lips  as  shown  in  Fig.  129  it  is  possible  to  give  some 


114 


A.CTIC  \l.    oiM'Ilono.NTI  \ 


idea  of  what  the  change  will  be  in  the  face.  Pig.  130,  a  and  b,  shows  the 
appearance  of  the  lips  before  and  after  the  placing  of  the  wax.  In  disto- 
clusion  cases  with  protruding  anterior  teeth,  such  as  we  find  in  Fig. 
131-a,  the  mandible  can  be  protruded  until  the  teeth  are  brought  into  the 
position  shown  in  Fig.  131-&,  which  is  a  position  assuming  a  normal  me- 
sio-distal  relation  of  the  arches.     The  facial  deformity  is  shown  in  Fig. 


Fig.   U.S. — Retraction  of  the  mandible  accompanying  a  branchial   fistula  of  the  first  clefts.     (Blair.) 


132-a,  and  the  resulting  change  produced  by  the  forward  movement  of 
the  mandible  is  shown  in  Fig.  132-6. 

The  resulting  changes  produced  by  the  treatment  of  mesioclusion  eases 
cannot  so  easily  be  demonstrated,  owing  to  the  fact  that  it  is  impossible 
for  the  patienl  to  retrude  the  mandible  sufficiently  far  to  show  any  im- 
provement. 


MALOCCLUSION 


11. 


Fig.   129. —  Shows  Lischer's  method  for  estimating  in  advance   the  probable  effect  of  an  orthi 
treatment;  compare  with  Fig.  130.     (Lischer.) 


Fig.    130. — Photographs   of   patient    liefore    and    after   the    use    of    the    wax    models    shown    in    Fi 

129-6.         (Lischer.) 


in; 


PRACTICAL    ORTHODONTl  \ 


Fig.    131. — Method    employed    in    distoclusions;    compare    with    Fig.    132    a    and    h.      (Lischer.) 


Fig.    132. — Photographs    of    patient    shown    in    Fig.    131    a    and    b;    note    change    in    profile    in    b. 

(Lischer.) 


CHAPTER  IV 

ETIOLOGY  OF  MALOCCLUSION 

Etiologic  factors  of  malocclusion  may  he  divided  into  two  groups, 
based  upon  the  time  in  which  the  factor  occurs  and  the  manner  of  the 
occurrence.  As  to  time,  they  are  divided  into  inherited,  congenital, 
and  acquired.  As  to  manner,  they  are  divided  into  local  and  general. 
General  causes  are  also  called  constitutional. 

General  or  Constitutional  Causes 

General  or  constitutional  causes  of  malocclusion  include  those,  that 
affect  the  general  functions  or  metabolism  of  the  individual  to  such 
an  extent  as  to  interfere  with  the  development  of  the  teeth  or  the  sur- 
rounding structures  supporting  the  teeth.  There  are  a  number  of 
diseases  that  affect  the  general  health  of  the  individual  to  such  an  ex- 
lent  as  to  interfere  with  the  normal  forces  of  occlusion  and  therefore 
produce  malocclusion.  There  are  more  general  diseases  that  affect 
the  development  of  the  complete  dental  apparatus  one  way  or  an- 
other than  was  formerly  supposed  to  exist.  There  are  a  few  that  pro- 
duce conditions  that  are  known  to  have  a  direct  bearing  upon  maloc- 
clusion. First  would  be  included  all_  of  those  diseases  of  childhood 
that  are  accompanied  with  high  temperatures.  Scarlet  fever,  measles, 
chicken-pox  and  similar  diseases  are  known  to  exert  a  deleterious  effect 
upon  the  epithelial  structures.  They  affect  the  formation  of  the  enamel 
of  the  teeth  to  such  an  extent  as  to  produce  atrophy  of  the  enamel 
organ,  thereby  causing  a  tooth  that  is  faulty  in  shape,  which  in  turn 
destroys  the  force  of  the  inclined  plane  or  the  approximal  contact. 
Syphilis  has  long  been  considered  as  a  disease  that  produces  atrophy 
of  the  enamel  organ,  and  there  is  little  doubt  but  that  it  does  produce 
certain  forms  of  crowns,  which  have  been  referred  to  as  "Hutchinson's 
teeth,"  but  there  are  also  a  great  many  other  diseases  that  produce  the 
same  kind  of  crowns.  In  some  cases,  the  general  disturbance  may  be 
so  great  as  to  destroy  the  tooth  germ  entirely,  which  would  then  pro- 
duce a  cause  of  malocclusion,  namely,  missing  teeth. 

Rickets  is  another  general  disease  that  produces  a  great  many  cases 
of  malocclusion.  Rickets  is  a  disease  of  malnutrition  characterized 
by  faulty  bone  formation.     As  a   result  of  the  faulty  bone  formation 

117 


1  IS  PRACTICAL    ORTHODONT]  \ 

proper  support  is  not  provided  for  the  teeth.  The  teeth  being  sup- 
ported by  a  faulty  calcified  alveolar  process,  have  not  enough  support 
to  prevent  them  from  assuming  a  position  of  malocclusion  under  the 
stress  of  mastication.  The  muscles  of  mastication  exert  force  upon 
the  bone  which  results  in  deformity  of  the  bone.  The  body  of  the  bone, 
as  well  as  the  alveolar  process,  is  abnormal  and  the  pull  of  the  muscles 
of  mastication  causes  the  mandible  to  straighten  out  at  the  angle,  which 
results  in  an  elongated  and  deformed  mandible.  Blair  considers  such 
deformities  of  the  mandible  as  a  sure  indication  of  early  rickets.  The 
alveolar  process  is  greatly  thickened,  as  shown  in  Fig.  134,  and  this 
thickening  of  the  alveolar  process  can  be  seen  as  thick  ridges  in  the 
living  individual.  The  gums  are  thick  and  more  or  less  inflamed.  In 
those  cases  where  a  thick  alveolar  ridge  is  encountered  the  practitioner 


Fig.    133. — Skull  of  opossum  that  suffered   from   rickets.      (Bebb's  Collection.) 

should  be  careful  in  making  promises  as  to  what  the  final  outcome  of 
the  case  will  be ;  for  in  rickets  the  teeth  can  be  moved,  but  they  will 
move  to  some  position  of  malocclusion  under  the  stress  of  mastication 
just  as  easily  as  they  move  with  an  appliance.  Rickets  has  been  de- 
scribed as  a  disease  of  childhood,  but  it  may  also  make  its  appearance 
in  the  middle-aged,  and  several  cases  have  been  reported  in  pregnant 
women  and  in  nursing  mothers.  It  is  plain  to  be  seen  that  if  the 
mother  was  rickety  the  teeth  of  the  child  would  be  doubly  affected. 
With  rickets,  the  deciduous  teeth  erupt  late,  and  there  is  a  general 
deformity  of  the  skull  and  jaws  in  the  more  extreme  cases.  However, 
children  may  have  rickets  and  the  disease  not  be  diagnosed  as  a  general 
disturbance  and  still  the  disease  will  be  the  cause  of  extreme  maloc- 
clusions. AVe  have  stated  that  the  deciduous  teeth  are  erupted  late 
and  the  conditions  with  regard  to  malocclusion  are  made1  worse,  owing 


ETIOLOGY    OF    MALOCCLUSION 


11!) 


to  the  fact  that  the  deciduous  teeth  are  lost  early.  The  roots  are  ab- 
sorbed without  any  apparent  reason.  With  regard  to  the  permanent 
teeth,  they  erupt  late,  and  if  the  disease  is  rather  marked,  owing  to  the 
deformed  jaws  and  processes,  they  take  extreme  positions  of  malocclu- 
sion. The  upper  arch  is  always  narrow  and  contracted  with  a  tendency 
to  the  formation  of  thick  ridges  in  the  palate  located  to  the  lingual 
side  of  the  molars  and  premolars.  The  lower  dental  arch  is  usually 
wide  in  the  molar  and  premolar  region,  with  the  crowns  of  the  teeth 
turned  in  and   the  apices  of  the  roots  turned  buccally.     Rickets  mav 


Fig.    134. — Superior    maxilla    of   ape    that    died    from    rickets.      (Rebl/s    Collection.) 


be  present  for  only  a  short  time,  but  this  will  be  long  enough  to  dis- 
turb some  of  the  forces  of  occlusion,  which  will  cause  the  malocclusion 
to  start,  and  the  case  will  then  be  made  worse  by  other  conditions 
that  develop  later  in  life.  Tt  must  be  remembered  that,  as  rickets  is 
a  disease  of  malnutrition,  it  is  found  in  the  two  extremes  of  society — 
the  rich  and  the  poor.  The  great  middle  class  who  have  sufficient  of  the 
coarser  foods  and  are  able  to  live  in  good  surroundings  are  free  from 
rickets  as  compared  with  the  poor  who  have  to  live  in  the  poor  sur- 
roundings and  witli  the  rich  who  have  sufficient  food  but  food  of  the 
improper  kind.     It  is  from  this  latter  class  that  most  of  the  orthodontic 


120 


PRACTICAL    ORTHODONTIA 


Fig.   135. 


Fig.    136. 
Figs.    135   and   136. — Malocclusion   in   which   there   was   a   history   of   rickets. 


ETIOLOGY    OF    MALOCCLUSION  121 

cases  are  seen  in  private  practice  with  rickets.  It  must  also  be  remem- 
bered that  we  may  find  the  disease  in  varying  degrees  of  severity,  and 
as  a  result  of  this  the  disease  will  produce  different  types  of  malocclu- 
sion depending  upon  the  other  causes  that  may  be  present. 

It  has  long  been  recognized  that  the  early  loss  of  the  deciduous 
teeth  would  produce  malocclusions,  and  as  this  is  one  of  the  conditions 
that  is  always  present  in  rickets,  we  have  little  doubt  that  rickets  has 
produced  many  cases  of  malocclusion  in  which  this  primary  cause  has 
never  been  recognized.  The  predisposing  factors  in  the  production  of 
malocclusion  are  made  more  manifest,  when  we  remember  that  the 
late  eruption  of  the  permanent  teeth  always  causes  malocclusion  and 
that  it  is  also  one  of  the  results  of  rickets.  Patients  who  are  rickety 
are  also  prone  to  be  mouth-breathers  and  to  suffer  with  enlarged  ton- 
sils and  adenoids.  In  fact,  the  hypertrophy  of  lymphoid  tissue  is  an- 
other link  of  the  chain  of  conditions  that  is  found  in  rickets  and  an- 
other of  the  conditions  that  produces  malocclusion.  Figs.  135  and  136 
show  a  case  of  malocclusion  in  which  there  was  a  history  of  rickets, 
and  the  malocclusion  is  typical  of  those  conditions.  The  upper  arch 
is  narrow,  with  thick  <mms  and  alveolar  processes,  wide  lower  arch  in 
the  region  of  the  molars  and  premolars.  The  facial  development  of 
the  patient  showed  a  deformed  mandible;  one  in  which  the  angle  was 
made  obtuse  by  the  action  of  the  muscles  of  mastication.  In  treating 
this  case  the  teeth  moved  very  easily,  and  in  retention  they  moved  to 
new  positions  of  malocclusion  just  as  easily.  More  will  be  said  in  re- 
gard to  these  conditions  under  treatment. 

I'libereulusis  also  produces  conditions  that  affect  the  teeth,  but  they 
are  not  so  severe  as  those  produced  by  rickets  and  the  results  are  al- 
most directly  opposite.  A  child  suffering  from  tuberculosis  will  erupt 
the  deciduous  and  permanent  Teeth  early.  After  a  deciduous  tooth 
takes  its  place,  the  root  will  not  be  absorbed  as  it  should  and  the  per- 
manent tooth  will  take  a  position  somewhere  to  the  side  of  it.  How- 
ever, the  deformity  caused  by  the  prolonged  retention  of  a  deciduous 
tooth  does  not  produce  the  harm  that  the  early  loss  of  the  deciduous 
tooth  would  produce. 

The  reason  why  these  tAvo  constitutional  diseases  should  act  as  they 
do  has  not  been  fully  explained,  but  a  great  many  who  confine  their 
practice  to  the  diseases  of  children  have  tabulated  the  conditions  as 
herein  mentioned. 

Another  constitutional  condition  producing  malocclusion  is  the  faulty 
development  of  the  child,  which  may  be  the  result  of  several  conditions. 


122  PRACTICAL   ORTHODONTIA 

Under  the  head  of  faulty  development  may   be  considered  conditions 

that  arise  from  faulty  cell  metabolism  or  improper  growth  of  the 
youngster  which  may  be  the  result  of  conditions  that  are  acquired 
or  congenital.  In  fact,  it  has  been  suggested  by  some  writers  that 
even  hereditary  influences  may  cause  an  ill  effect  upon  the  develop- 
ment of  the  child,  which  will  result  in  malocclusion.  This  docs  not 
mean  that  the  malocclusion  of  the  teeth  themselves  is  an  inherited 
condition  but  that  owing  to  imperfect  germ  cells  or  germ  cells  that 
are  below  par  the  child  will  develop  and  possess  a  physical  organism 
which  is  not  capable  of  withstanding  the  influences  surrounding  him, 
with  the  result  that  he  develops  improperly  or  poorly  and  as  a  further 
result,  malocclusions  of  the  teeth  are  present.  In  these  conditions 
malocclusion  is  not  only  present  but  there  is  a  lowered  physical  state 
of  the  entire  individual,  in  fact,  the  child  is  below  normal  in  every 
respect.  From  a  biologic  standpoint  this  condition  may  be  compared 
with  what  would  take  place  if  we  were  to  plant  a  seed  of  a  plant  that 
did  not  have  the  proper  quality.  In  other  words,  if  we  should  select 
the  seed  from  a  plant  that  had  grown  in  an  environment  that  rendered 
the  plant  below  normal,  Ave  would  expect  the  next  generation  of  those 
plants  raised  from  that  same  seed  to  be  of  a  poor  physical  quality.  As 
a  result  of  this  faulty  cell  metabolism,  faulty  development  may  be  the 
result  of  the  union  of  germ  cells  that  do  not  possess  as  much  vitality 
as  is  ordinarily  possessed  by  germ  cells  that  are  said  to  be  one  hundred 
per  cent  perfect.  Therefore,  a  great  many  constitutional  conditions 
that  would  affect  flic  general  metabolism  of  the  individual  may  be  the 
result  of  unhealthy  germ  cells  or  rather  are  produced  by  the  union  of 
germ  cells  that  are  below  par.  As  a  result  of  this  we  may  say  that 
certain  types  of  malocclusion  or  certain  constitutional  conditions  that 
will  influence  malocclusion  have  their  beginning  with  the  union  of  the 
germ  cells.  In  other  words,  Ave  would  not  expect  a  child  Avho  was  the 
result  of  the  union  of  two  germ  cells  that  were  below  par  to  develop 
in  the  same  physical  manner  as  a  child  who  was  the  result  of  a  union 
of  healthy  germ  cells.  Therefore,  the  child  from  the  germ  cells  that  are 
below  par  will  develop  all  manner  of  physical  ailments  and  show  ab- 
normal and  retarded  development  in  every  respect,  and  of  course  among 
these  will  be  the  maldevelopmenl  of  his  teeth  and  their  supporting 
structures. 

Another  factor  that  influences  the  development  of  malocclusion,  be- 
cause it  influences  the  cell  metabolism,  is  the  condition  that  may  be 
said  to  be  congenital.  Tn  other  Avords,  if  during  pregnancy  the  mother 
is  below  par,   improperly  fed  and   improperly   nourished,   it    will   affect 


ETIOLOGY    OF    MALOCCLUSION  123 

the  development  of  the  child  to  such  an  extent  that  the  child  will  also 
be  poorly  developed  and  poorly  nourished.  It  is  a  well-known  fact  that 
the  calcification  of  the  deciduous  teeth,  and  certain  of  the  permanent 
teeth,  begins  before  birth.  Therefore,  if  before  birth,  the  mother  is 
poorly  nourished  we  would  expect  improper  calcification  of  the  decidu- 
ous teeth  and  some  of  the  permanent  teeth  and  improper  calcification  of 
the  mandible  and  the  maxilla  as  well  as  the  disturbance  of  other  gen- 
eral organs. 

It  is  a  well-known  fact  that  children  born  of  mothers  who  have 
been  forced  to  do  a  Large  amount  of  physical  labor  during  pregnancy, 
who  are  overworked  and  underfed,  give  birth  to  children  who  show 
physical  imperfections  in  a  great  many  respects.  While  some  of  these 
physical  conditions  may  be  apparent,  there  are  other  conditions  that 
pass  unnoticed  but  which  exert  a  deleterious  influence  later  in  the  life 
of  the  child,  and  this  influence  may  make  itself  apparent  by  the  pro- 
duction of  deformities  in  the  teeth  and  jaws.  Certain  constitutional 
conditions  that  may  he  said  to  be  congenital  have  been  acquired  from 
the  mother  during  pregnancy  and  they  play  a  very  important  part  in 
the  development  of  malocclusion,  although  the  malocclusions  may  not 
make  their  appearance  until  much  later  in  the  life  of  the  child.  It 
must  also  be  remembered  that  the  child  who  has  been  improperly  nour- 
ished during  embryonic  life  will  also  be  subjected  to  a  greater  degree 
to  the  influences  of  environment,  and  will  be  more  susceptible  to  dis- 
ease than  the  child  who  developed  from  the  embryo  that  was  properly 
nourished.  As  a  result  of  this,  we  shall  find  that  some  conditions 
will  produce  malocclusions  in  one  child,  while  a  similar  condition  would 
be  thrown  off  and  have  no  apparent  effect  on  another  child.  It  must, 
therefore,  be  remembered  in  studying  the  etiologic  factors  of  maloc- 
clusion that  a  great  many  cases  that  are  obscure  as  to  the  cause  really 
have  their  beginning  in  the  embryonic  period  and  are  the  result  of 
constitutional  conditions  that  developed  during  the  embryonic  life,  ('ell 
metabolism  or  faulty  development  plays  a  much  greater  part  than  has 
been  supposed.  The  long  period  of  time  during  which  it  can  act.  and 
is  in  an  active  state,  and  every  angle  of  the  physical  and  embryologic 
development  of  the  child  make  il  a  factor  to  which  more  attention  must 
he  given,  one  which  must  he  recognized  to  a  greater  extent  than  hereto- 
fore. We  might  therefore  divide  constitutional  conditions  into  three 
periods.  Constitutional  conditions  or  developments  that  are  the  result 
of  conditions  of  health  transmitted  by  the  germ  cells  or  are  the  result 
of  the  physical  vitality  of  the  germ  cells  at  the  time  of  fertilization; 
constitutional  conditions  that    may  arise  during  the  congenital  period 


124  PRACTICAL    ORTHODONTIA 

and  that  are  the  result  of  environment  or  physical  conditions  in  which 
the  mother  lived ;  and  last,  constitutional  conditions  that  are  the  result 
of  environment  in  which  the  child  lives.  The  third  factor  plays  a  great 
part  in  the  production  of  malocclusion,  and  of  course  will  play  a  part 
depending  to  a  certain  extent  upon  the  other  two  factors. 

However,  it  is  a  well-known  fact  that  children  may  have  developed 
normally  as  the  result  of  hereditary  influences,  as  a  result  of  the  trans- 
mitted physical  conditions  of  the  germ  cells,  and  during  the  congenital 
or  prenatal  period,  but  that  they  Avill  develop  malocclusions  as  a  re- 
sult of  the  environment  in  which  they  live.  These  environments  pro- 
duce malocclusions  as  constitutional  disturbances,  owing  to  the  fact 
that  the  environment  affects  the  entire  physical  condition  of  these 
youngsters.  As  a  result  of  these  environments  in  which  the  child  lives 
and  as  a  result  of  constitutional  conditions  that  are  produced  thereby, 
we  may  say  that  a  certain  number  of  malocclusions  are  the  result  of 
civilization. 

One  of  the  greatest  factors  in  the  production  of  malocclusion  today, 
acting  in  a  constitutional  manner,  is  the  effect  of  food  and  diet  upon 
the  teeth  directly  and  upon  the  constitution  as  a  whole.  In  order  for 
the  osseous  structures  or  calcified  tissues  to  develop,  the  children  must 
have  the  proper  kind  of  food,  and  a  large  number  of  civilized  youngsters 
do  not  have  the  proper  kind  of  food.  The  children  of  the  better  class 
of  people  or  the  rich  people  are  particularly  liable  to  be  affected  in  this 
manner  because  the  child  is  very  likely  to  eat  food  containing  a  large 
amount  of  starch  and  sugars,  a  large  amount  of  meat,  and  food  that 
contains  very  little  of  calcified  tissue-builders.  Foods  should  be  used 
that  contain  lime,  salts,  and  similar  substances,  such  as  are  present  in 
whole-wheat  bread  and  also  present  to  a  large  extent  in  certain  vegeta- 
bles and  vegetable  fibers.  As  a  result  of  improper  diet,  the  osseous  struc- 
tures of  the  individual  will  not  be  properly  developed,  on  account  of  the 
fact  that  the  eating  of  this  improper  food  does  not  require  the  proper 
usage  of  the  jaws.  It  is  a  well-known  fact  that  for  any  organ  to  be  de- 
veloped it  must  be  used,  and  this  is  equally  true  in  regard  to  the  teeth 
and  their  supporting  structures.  The  child  is  not  receiving  the  food 
that  requires  the  proper  mastication,  so  the  teeth  are  not  used  and  pres- 
sure is  not  brought  to  bear  upon  the  teeth,  and  therefore  no  pressure  is 
transmitted  to  the  alveolar  process  and  the  structures  supporting  the 
teeth. 

As  the  teeth  are  not  properly  used,  there  is  not  the  proper  circulation 


ETIOLOGY    OF    MALOCCLUSION  L25 

to  the  parts  and  therefore  not  the  proper  development.  Associated 
with  the  improper  usage  of  the  teeth  or  lack  of  use  will  also  be  a  lack  of 
action  brought  to  bear  on  the  muscles  surrounding-  the  teeth  and  jaws. 
As  a  result  of  disuse  there  is  a  lack  of  muscular  development,  a  lack  of 
the  stimulating  influences  produced  by  muscular  activity,  and  the  en- 
tire face  and  jaws  of  the  child  do  not  develop  properly  because  of  this 
lack  of  function.  "We  see  a  great  many  children  who  have  perfectly 
normal  deciduous  teeth  as  far  as  the  shape  of  the  teeth  and  the  shape  of 
the  arches  are  concerned,  and  everything  indicates  if  they  would  live 
properly  and  in  the  proper  environment  that  they  would  have  a  normal 
permanent  dentition.  However,  without  any  apparent  reason,  so  far  as 
we  can  find  direct  pathologic  factors,  the  child  does  not  develop,  its 
face  does  not  grow  properly  and  the  dental  apparatus  is  not  developed 
sufficient  to  accommodate  the  permanent  teeth.  This  lack  of  dental  de- 
velopment is  the  result  of  faulty  cell  metabolism  and  the  lack  of  growth 
that  is  produced  by  the  lack  of  use.  We  maintain  that  this  is  the  result 
of  the  lack  of  use,  because  in  the  early  life  of  the  child  he  had  the  phys- 
ical development  that  produced  a  normal  set  of  deciduous  teeth.  Every- 
thing indicates  that  he  started  out  along  a  normal  path  of  develop- 
ment but  that  for  some  reason,  between  the  time  of  eruption  of  the 
deciduous  teeth  and  the  eruption  of  the  permanent  teeth,  something- 
has  gone  wrong  in  nature's  plan  and  the  permanent  dentition  has  not 
developed  to  a  normal  shape  and  size.  This  something  that  has  gone 
wrong  is  in  the  majority  of  cases  the  result  of  the  environment  in 
which  he  lives,  the  lack  of  use  to  which  the  teeth  have  been  put,  the 
lack  of  function  of  the  muscles  of  mastication,  and  a  general  lack  of 
development  that  has  been  produced  by  lack  of  use.  In  other  words, 
the  malocclusion  has  been  the  result  of  the  environment  in  which  he 
lives,  and  that  environment  has  affected  the  constitutional  develop- 
ment or  conditions  of  the  youngster  to  such  an  extent  that  malocclu- 
sions are  present.  We  find  that  malocclusions  make  their  appearance 
in  different  races  provided  that  the  races  live  in  such  an  environment 
as  we  have  described.  We  find  that  malocclusions  are  present  among 
the  civilized  Indians  who  are  living  in  luxury,  among  the  negroes  who 
are  living  as  white  people  live,  so  we  can  safely  say  that  racial  charac- 
teristics are  neither  a  preventive  of  malocclusion  nor  a  producer  of  it. 
Many  malocclusions  are  the  result  of  the  environment  in  which  the  in- 
dividual lives,  the  result  of  disuse  that  affects  the  constitutional  devel- 
opment, and  thereby  produces  the  malocclusion. 


126 


I'KACTIC  \l.    ()l,"l'IK)|)().\"l'l  \ 


In  examining  skulls  of  ancient  races,  such  as  the  one  shown  in  Fig. 
137,  which  is  the  skull  of  an  old  Indian,  we  find  the  teeth  well  de- 
veloped, the  jaws  well  developed,  and  a  large  amount  of  wear  shown 
in  the  teeth.  If  the  modern  individual  used  his  teeth  in  such  a  man- 
ner as  the  semi-savage  used  his,  a  large  amount  of  malocclusion  that 
is  the  result  of  environment  and  Lack  of  use  would  disappear  and  nor- 
mal occlusions  would  be  much  more  common  in  the  civilized  man  than 
they  are  at  present.  If  must  be  remembered  then  that  a  large  num- 
ber of  the  obscure  cases  of  malocclusion  have  their  origin  and  faultv 


Fig.    137.— Showing    well  cleveloi  c-<l    jaw-    and 


if    i,<  ih 


a    result    of    use. 


cell  metabolism  in  a  faulty  development  and  that  this  faulty  develop- 
ment may  reach  far  back  into  the  period  that  may  be  said  to  be  the 
period  of  environment  in  which  the  child  lives,  to  be  a  congenital  con- 
dition that  has  been  acquired  during  embryonic  life,  or  even  to  be  a 
constitutional  condition  that  may  be  produced  by  the  physical  nature 
or  condition  of  the  germ  cells.  Constitutional  conditions  as  the  cause 
of  malocclusion  must  have  a  much  greater  study  than  they  have  re- 
ceived in  time  past. 

Another   factor   that    iN   the   cause   of    faulty   developments   and    that 


ETIOLOGY    OF    MALOCCLUSION  1_  i 

plays  a  part  in  the  development  of  malocclusion  is  disease  of  the  duet- 
less  glands  of  which  very  little  is  known.  It  is  known  that  diseases 
of  the  pituitary  bodies  have  a  tendency  to  produce  overdevelopment 
and  are  especially  liable  to  produce  overdevelopment  of  the  mandible. 
Not  only  will  it  produce  overdevelopment  of  the  mandible  but  it  will 
affect  the  development  of  the  other  bones  of  the  face  to  a  certain  ex- 
tent, but  the  overdevelopment  of  the  mandible  is  more  apparent,  be- 
cause in  the  development  of  that  bone  we  have  the  malocclusion  pro- 
duced directly.  A  great  many  cases  of  so-called  mesioclusion,  or  Class 
III,  have  been  the  result  of  the  development  of  the  mandible,  which 
really  are  conditions  arising  from  overgrowth  of  that  bone,  and  there- 
fore are  a  macromandibular  development.  Diseases  of  the  thyroid  will 
produce  a  lack  of  development  of  the  osseous  structure  and  very  proba- 
bly a  great  many  of  our  patients  who  show  a  lack  of  osse  ius  develop- 
ment are  children  who  are  suffering  from  thyroid  deficiency. 

In  a  prognosis  of  these  conditions  it  is  well  to  be  on  our  guard  and 
not  to  make  too  positive  a  statement  as  to  what  can  be  done  in  the 
treatment  of  malocclusion,  for  very  often  the  malocclusion  is  the  re- 
sult of  the  constitutional  condition  that  may  at  the  present  time  be  be- 
yond the  control  of  even  internal  or  general  medicine.  The  known 
facts  at  present  seem  to  indicate  thai  a  larger  number  of  malocclusions 
are  produced  by  constitutional  conditions  and  that  instead  of  maloc- 
clusion being  purely  a  local  proposition  as  the  result  of  disturbed  me- 
chanical factors,  as  was  formerly  supposed,  we  have  to  admit  that  a 
great  many  malocclusions  are  the  result  of  disturbed  cell  metabolism. 
which  is  now  considered  ;is  the  first  and  most  important  force  of  occlu- 
sion. Furthermore,  if  normal  cell  metabolism  cannot  be  established 
the  malocclusion  will  be  more  or  less  permanent  and  the  treatment  of 
it   unsatisfactory. 

Another  constitutional  factor  that  plays  a  great  part  in  the  produc- 
tion of  malocclusion,  which  has  been  referred  to  indirectly,  is  that 
which  is  the  result  of  early  feeding  of  the  youngster.  We  refer  par- 
ticularly to  the  prevalence  of  malocclusion  in  bottle-fed  babies  as  com- 
pared with  the  children  who  are  breast-fed.  Bottle-fed  babies  are  prob- 
ably improperly  nourished,  owing  to  the  fact  that  the  modified  milk  that 
they  receive  does  not  contain  some  of  the  elements  that  are  present  in 
mother's  milk,  even  though  chemical  analysis  would  seem  to  indicate 
that  it  is  the  same.  In  the  investigations  made  by  Hellman,  extending 
over  a  number  of  years,  he  has  found  that  malocclusions  in  bottle-fed 
children  are  much  more  numerous  than  malocclusion  in  normally  fed 
children.     Therefore,  malocclusion,  instead  of  being  the  condition  that 


128 


PRACTIC  VL    ORTHODONT]  \ 


may  arise  during  the  few  years  of  child  life,  is  probably  the  result  of 
conditions  that  extend  over  the  entire  developmental  period  of  the 
youngster,  beginning  with  the  germ  cells,  and  extending  over  a  period 
of  time  until  the  death  of  the  individual.  In  other  words,  there  is  no 
period  in  the  life  of  the  person  when  he  is  existing  either  as  a  single 
cell  or  as  a  complete  organism,  that  the  constitutional  conditions  can- 
not be  manifested,  and  there  is  no  period  during  that  time  when  con- 
stitutional conditions  may  not  occur  that  will  produce  malocclusion  of 
the  teeth. 

Local  Causes 

Local  causes  of  malocclusion  are  those  that  act  directly  within  the 
oral  cavity  and  its  parts.     They  include  such  conditions  as  affect  the 


Fig.    138. — Showing   nasopharynx,    hard   and    soft    palate,    and    location    of   adenoids    shown    at   X. 


ETIOLOGY    OF    MALOCCLUSION  129 

teeth  and  surrounding  structures.  At  first  it  would  seem  easy  to  sep- 
arate local  from  constitutional  causes  and  a  number  of  those  conditions 
are  easily  separable.  However,  there  are  other  conditions  that  may  be 
said  to  be  both  local  and  constitutional,  and  it  is  hard  to  determine  which 
may  have  been  the  primary  cause.  In  discussing-  constitutional  causes, 
we  stated  that  rickets  caused  an  early  loss  of  the  deciduous  teeth  and 
the  tardy  eruptions  of  the  permanent  teeth.  These  two  things  would 
act  locally  while  the  cause  of  them  would  be  constitutional.  But,  as  be- 
fore stated,  these  local  conditions  are  the  result  of  a  constitutional  con- 
dition. Mouth-breathing  has  long  been  given  as  a  local  cause  of  maloc- 
clusion because  it  disturbs  the  muscular  and  atmospheric  pressure  and 
acts  directly  upon  the  surrounding  structures.  The  majority  of  cases 
of  mouth-breathing  are  caused  by  hypertrophy  of  the  lymphoid  tissue 
located  in  the  naso-pharynx,  also  known  as  the  pharyngeal  tonsil  (see 
Fig.  138).  Therefore  the  real  cause  of  the  mouth-breathing  is  the  ade- 
noids, which  may  be  the  result_jof  a  constitutional  condition  or  of  the 
environment  in  which  the  child  is  living.  The  local  disturbance  is  the 
direct  cause  of  the  malocclusion,  but  the  factor  that  caused  the  ade- 
noids may  have  been  overlooked.  When  we  look  at  some  causes  in  this 
light  we  are  forced  to  admit  that  the  line  between  the  local  and  con- 
stitutional causes  blends  together  to  such  an  extent  as  to  be  almost  in- 
separable. However,  the  majority  of  malocclusions  are  surely  the  re- 
sult of  local  disturbances  or  the  result  of  environment.  As  there  are 
a  great  number  of  local  causes,  this  subject  will  be  discussed  more 
thoroughly  later.  We  will  now  take  up  a  different  plan  of  classifica- 
tion of  causes. 

Inherited,  Congenital  and  Acquired  Causes 

The  causes  of  malocclusion  may  be  divided  again  into  three  groups, 
according  to  the  time  in  which  they  originate  or  according  to  the  time 
of  origin.     They  are  hereditary,  or  inherited,  congenital,  and  acquired. 

Inherited  Causes. — An  inherited  condition  is  one  that  is  transmit- 
ted from  the  parent  to  the  child.  An  inherited  malocclusion  would  be 
one  that  was  present  in  the  parent  and  transmitted  to  the  offspring. 
Owing  to  the  fact  that  much  has  been  written  on  the  inheritance  of 
malocclusion,  it  will  be  necessary  to  review  some  of  the  theories  for  and 
against,  as  advocated  by  authorities  formerly  and  at  the  present  time. 
The  evidence  may  be  divided  into  biologic  and  clinical.  From  the 
standpoint  of  biology,  anatomy,  histology  and  embryology,  there  is  no 
evidence  that  malocclusion  is  ever  inherited.     The  author  has  seen  but 


130  PRACTICAL    ORTHODONTIA 

few  eases  of  malocclusion  that  were  not  the  result  of  some  congenital 
or  acquired  cause.  A  child  inherits  a  great  many  things  from  its  par- 
ents. It  inherits  a  great  many  characteristics.  A  child  with  white  par- 
ents is  white ;  a  child  with  negro  parents  is  a  negro ;  a  bird  hatched 
from  a  duck  egg  will  be  a  duck  and  one  from  a  chicken  egg  will  be  a 
chicken.  A  child  also  inherits  certain  conditions  that  have  been  the 
result  of  the  working  of  environment  upon  the  human  race  for  a  great 
number  of  years.  A  child  inherits  a  certain  number  of  things  that  make 
up  the  dental  apparatus.  The  teeth  are  so  arranged  as  to  be  in  normal 
occlusion.  Any  deviation  from  normal  occlusion  is  the  result  of  some 
acquired  or  congenital  condition.  It  is  a  well-known  fact  that  character- 
istics that  arise  spontaneously  and  that  are  spoken  of  as  variations  are 
not  as  a  rule  transmitted  unless  they  are  a  decided  advantage  to  the 
offspring.  Any  variation  that  is  not  impressed  upon  the  germ  cell  will 
not  be  transmitted.  Each  individual  germ  cell  possesses  a  certain 
amount  of  chromatin  that  presides  over  inheritance.  In  order  that  a 
child  may  inherit  malocclusion,  the  malocclusion  must  be  impressed  upon 
the  chromatin  of  the  germ  cell.  We  have  no  evidence  that  such  a  thing 
can  occur.  After  the  union  of  the  male  and  female  pronucleus,  the  em- 
bryo develops  as  a  separate  organism  in  which  is  contained  the  sum 
total  of  all  the  characteristics  carried  by  the  male  and  female  germ  cell. 
The  offspring  may  resemble  one  or  the  other  of  the  parents,  or  may  be 
a  blending  of  the  two;  if  a  blending  of  the  two,  the  offspring  will  not 
exactly  resemble  either  parent.  The  author  does  not  feel  that  any  other 
condition  can  occur,  as  no  other  conditions  except  those  above  mentioned 
can  be  found  anywhere  in  biology.  On  the  other  hand  those  who  advo- 
cate the  inheritance  of  malocclusion,  and  a  certain  number  of  men  do, 
maintain  that  certain  types  of  malocclusion  are  transmitted. 

One  type  is  called  family  traits.  They  refer  to  such  conditions  as 
the  protruding  of  the  lower  teeth,  or  mesioclusion  cases,  or  protrusion  of 
the  upper  teeth,  or  distoclusion  with  Labioversion  of  the  maxillary  an- 
terior teeth.  We  do  find  Class  II,  Division  1  cases  in  parents,  uncles 
and  aunts,  and  sometimes  in  several  of  the  children,  but  it  has  not  been 
the  result  of  inheritance.  These  cases  have  been  produced  because  each 
one  of  those  individual  children  and  each  one  of  their  parents,  uncles 
and  aunts  who  have  distoclusion  with  labioversion  of  the  maxillary  an- 
terior teeth,  have  lived  in  exactly  the  same  environment  and  the  same 
pathologic  conditions  have  been  acquired  as  a  result  of  those  environ- 
ments, which  have  disturbed  the  forces  of  occlusion  so  as  to  produce 
that  particular  type  of  malocclusion.  Therefore,  such  conditions  as 
are  grouped  under  the  head  of  family  traits  by  other  authors  are  not  the 


ETIOLOGY    OF    MALOCCLUSION  131 

result  of  the  transmission  of  the  malocclusion,  but  the  result  of  acquired 
conditions  that  are  the  same  in  each  individual. 

Certain  constitutional  diseases  may  also  produce  malocclusions  in  the 
child  that  are  the  same  as  those  present  in  the  parent.  Rickets  is  one 
of  the  diseases  that  often  affects  both  the  child  and  the  parent,  and 
because  the  child  has  the  same  malocclusion  as  the  parent  the  mal- 
occlusion is  charged  to  inheritance  when  it  is  the  result  of  disease.  A 
certain  type  of  malocclusion  that  is  prevalent  in  one  of  the  royal  fam- 
ilies of  Europe  has  often  been  attributed  to  inheritance  when  clinical 
facts  indicate  that  the  entire  family  has  suffered  from  rickets. 

Certain  forms  of  malocclusion  are  sometimes  found  in  different  mem- 
bers of  the  same  family  and  the  cause  of  the  condition  may  often  be 
obscure.  However,  because  we  cannot  locate  the  trouble,  does  not  prove 
that  the  malocclusion  is  inherited.  The  author  has  seen  three  cousins 
in  three  different  families  who  had  very  peculiar  malocclusions,  all 
very  similar,  and  nothing-  could  be  found  that  should  produce  such  a 
condition.  The  author  has  seen  all  of  these  cases  under  treatment,  and 
the  treatment  of  all  lias  been  very  slow  and  unsatisfactory,  which  would 
indicate  some  constitutional  condition  was  playing  an  important  part 
in  the  production  of  the  malocclusion.  The  malocclusions  are  not  pres- 
ent in  any  of  the  male  cousins  of  the  family.  Unfortunately,  from  a 
scientific  standpoint,  the  three  families  are  small,  which  reduces  the 
law  of  average  so  much  as  to  make  it  useless. 

Cases  with  the  same  type  of  malocclusion  may  be  present  in  chil- 
dren of  the  same  family  and  inherited  factors  may  be  thought  to  be 
the  cause  of  these  conditions,  but  at  the  present  time,  we  have  not  suf- 
ficient knowledge  to  prove  that  they  are  the  result  of  inheritance. 
Figs.  139  and  140  are  those  of  sisters  that  present  very  similar  maloc- 
clusions. Figs.  141  and  142  represent  the  right  sides  of  the  same  cases. 
The  cause  of  these  cases  may  be  difficult  to  determine,  but  it  probably 
was  the  same  constitutional  condition  or  the  same  acquired  factors  in 
each  case,  and  not  the  result  of  inheritance. 

AVe  find  another  class  of  conditions  mentioned  by  those  who  advo- 
cate the  inheritance  of  malocclusion,  which  class  has  been  called  the 
intermarriage  of  races  or  the  mixing  of  types.  They  maintain  that  a 
certain  number  of  malocclusions  that  are  very  often  found  are  the  result 
of  the  marriage  of  parents  who  are  of  different  physical  size.  For  in- 
stance, they  say  that  a  child  will  often  inherit  the  teeth  of  a  large  father 
and  the  jaws  of  a  small  mother,  resulting  in  a  condition  in  Avhich  the 
teeth  are  too  large  for  the  jaws.    No  explanation  has  ever  been  made  as 


132 


PRACTICAL    ORTHODONTIA 


to  how  such  a  condition  could  occur.  To  any  one  who  is  familiar  with 
the  development  of  the  teeth  and  jaws  it  becomes  absolutely  impossible 
to  accept  such  a  doctrine.  The  child's  teeth  are  not  formed  from  one 
group  of  cells  and  the  jaws  from  another,  but  both  come  from  the 
branchial  skeleton,  and  up  to  a  certain  time  it  is  impossible  to  say  which 
cell  is  going  to  develop  into  a  tooth  and  which  cell  is  going  to  develop 


Fig.   139. 


Fig.    140. 


Fig.    141. 


Fig.    142. 


Figs.    139,    140,    141    and    142. — Similar    types    of    malocclusion   in    members    of    the    same    family. 
Claimed   by    some    to    be    inherited.      (Zentler.) 


into  the  jaws  or  bone  supporting  the  teeth.  The  size  of  the  child's 
teeth  was  determined  at  the  time  of  the  fertilization  of  the  ovum.  From 
that  time  on  until  the  eruption  of  the  permanent  teeth,  if  the  child 
leads  a  perfectly  norma]  life,  and  is  not  influenced  by  any  other  ac- 
quired cause  or  constitutional  disease,  the  arches  will  be  large  enough 
for  the  teeth.    The  size  of  the  teeth,  that  is,  the  enamel  of  the  teeth,  will 


ETIOLOGY    OF    MALOCCLUSION 


133 


not  be  changed  unless  there  is  an  actual  destruction  or  atrophy  of  the 
enamel  organ.  However,  the  size  of  the  hone  or  the  jaw  supporting  the 
teeth  depends  upon  the  environment  of  the  individual,  and  there  are  a 
number  of  conditions  that  will  retard  the  development  of  the  jaws 


Fig.    143. — Supernumerary   teeth,   congenital   cause   of   malocclusion. 


Fig.    144. — Supernumerary   teeth,   congenital  cause   of  malocclusion. 


and  produce  malocclusion  of  the  teeth.  The  author  has  never  seen 
a  case  of  malocclusion  that  has  been  the  result  of  such  inherited  condi- 
tions as  have  just  been  mentioned,  nor  has  he  ever  had  an  opportunity 


134  PRACTICAL   ORTHODONTIA 

to  inspect  a  case;  in  which  the  malocclusion  of  a  parent  was  transmitted 
to  the  offspring. 

Congenital  Causes. — Congenital  conditions  are  those  that  occur  in 
the  embryo  before  birth.  There  has  been  some  dispute  as  to  the  mean- 
ing of  inherited  and  congenital  causes.  Some  writers  have  used  the 
terms  synonymously.  It  may  be  said  that  all  inherited  conditions  are 
congenital,  but  congenital  conditions  are  not  always  inherited.  In  other 
words,  there  are  some  congenital  deformities  of  the  parents  that  will 
not  be  transmitted  to  the  offspring. 

The  most  frequent  congenital  conditions  that  have  to  do  with  mal- 
occlusion of  the  teeth  are  harelip  and  cleft  palate.  Harelip  and  cleft 
palate  occur  in  a  certain  number  of  cases  in  each  community,  that  is, 
they  occur  according  to  "the  law  of  average."  If  a  thousand  cases  were 
examined  in  one  community,  a  thousand  individuals  in  another  com- 
munity, and  a  thousand  in  the  third,  we  would  find  about  the  same 
number  of  harelips  and  cleft  palates  in  all  three  communities.  We  would 
find  just  as  many  cases  of  harelip  and  cleft  palate  in  one  family  as  we 
would  in  another.  At  certain  times  the  average  may  run  up  and  at 
others  it  will  be  diminished.  We  may  find  a  few  cases  where  the  par- 
ents and  some  of  the  children  in  the  same  family  have  harelips,  but 
after  that  there  might  be  generations  and  generations  in  which  these 
deformities  would  not  again  appear.  Harelip  and  cleft  palate  are 
simply  improper  unions  of  the  premaxillaa  with  the  maxillary  bud,  and 
these  conditions  exist  in  all  individuals  at  some  time  in  embryonic 
life.  Some  disturbance  that  occurred  during  the  intra-uterine  life  pro- 
duces a  failure  of  union  of  these  parts.  It  has  been  observed  that  the 
majority  of  harelip  and  cleft  palate  cases  occur  in  the  first-born  chil- 
dren, and  very  seldom  are  these  conditions  seen  in  children  born  after- 
ward. Some  authorities  maintain  that  it  is  caused  by  improper  stress 
that  has  forced  the  maxillary  and  premaxillary  bones  apart  and  pre- 
vented them  from  uniting. 

Another  congenital  condition  is  supernumerary  (Figs.  143  and  144) 
and  missing  teeth  (Figs.  145,  146  and  147).  We  find  the  supernumer- 
ary tooth  germ  present  before  birth  and  in  the  majority  of  missing 
teeth  germs  are  absent  at  birth.  A  few  cases  of  missing  teeth  will  be 
found  that  result  from  accident  or  disease  after  the  birth  of  the  child, 
in  which  case  the  condition  would  not  be  congenital.     The  lateral  (Fig. 

148)  incisors  and  premolars  are  most  frequently  absent. 

Abnormal  development  and  attachment  of  the  frenum  labium  (Fig. 

149)  is  also  congenital,  although  in  a  great  many  cases  this  condition 
does  not  assert  itself  until  some  time  after  birth. 


ETIOLOGY    OF    MALOCCLUSION 


135 


Fig.  145. 


Fig.   146. 
Figs.  145  and  146. — Missing  tooth  (maxillary  second  premolar),  congenital  cause  of  malocclusion. 


1::c 


PRACTICAL    ORTHODONTIA 


111  examining  a  large  number  of  newly  born  children  with  reference 
to  the  attachment  of  the  frenum  labium,  it  has  been  found  that  the  fre- 
num  is  always  attached  at  a  point  close  to  the  gingival  border  of  the 
gum.     It  is  also  large  and   thick.     The   lower  frenum,   as  well  as  the 


Fig.    147. — Congenital    missing    maxillary    second    premolar. 


Fig.    148. — Missing   lateral    incisor,    congenital    cause    of    malocclusion. 


upper  frenum,  may  be  well  developed.  As  the  child  grows  older  and  the 
deciduous  teeth  erupt,  we  find  that,  in  the  majority  of  cases,  the  teeth 
and  alveolar  process  grow  downward  or  gingivally  away  from  the  at- 
tachment of  the  frenum,   with  the  result   that  the  attachment  of  the 


ETIOLOGY    OF    MALOCCLUSION  137 

frenum  is  at  a  more  apical  point  compared  with  the  gingival  border 
than  it  was  at  birth.  There  is  also  a  tendency  for  the  frennm  to  de- 
crease in  size.  The  frenuxn  is  large  and  attached  close  to  the  gingival 
border  at  birth,  but  as  the  teeth  erupt  it  becomes  attached  at  a  point 
farther  from  the  gingival  border,  because  the  teeth  and  alveolar  proc- 
ess grow  away  from  it.  In  abnormal  cases,  the  attachment  of  the  fre- 
nnm continues  to  grow  downward  or  gingivally  with  the  gingival  growth 
of  the  teeth  and  process,  with  the  result  that  the  attachment  is  always 
between  the  teeth  and  causes  a  space  to  exist  between  the  incisors. 
We  find  some  cases  in  which  the  deciduous  teetli  will  he  normal  and 
the  attachment  of  the  frenum  during  the  time  the  deciduous  incisors  are 
present  will  also  lie  normal.     However,  with  the  eruption  of  the  perma- 


Fig.    149. — Abnormal    fremim    labium,   congenital   cause   of   malocclusion. 

nent  teeth,  and  the  growth  of  the  alveolar  process,  the  attachment  of 
the  frenum  grows  gingivally  as  the  permanent  teeth  erupt.  This  results 
in  the  appearance  of  an  abnormal  frenum  in  a  case  that  has  been  pre- 
viously normal. 

The  frenum  may  be  abnormal  in  the  upper  or  lower  lip,  but  the  ma- 
jority of  abnormal  frenums  are  found  in  the  upper  lip.  In  a  few 
instances  we  have  seen  the  frenum  abnormal  in  the  lower  lip  and  the 
upper  lip  presented  a  normal  condition.  Associated  and  with  abnor- 
mal frenums,  may  be  a  thickened  and  abnormal  lip.  The  lip  presents 
the  appearance  of  having  too  much  tissue  in  it  and  produces  a  very 
bad  facial  deformity,  besides  the  deformity  produced  by  the  maloc- 
clusion. In  some  cases,  the  frenum  will  be  too  short,  which  will  retard 
the  action  of  the  lip,  and  it  will  be  impossible  for  the  patient  to  use 


138 


PRACTICAL    ORTHODONTIA 


the  lip  as  he  should  or  to  raise  the  lip  in  smiling  to  give  the  proper 
facial  expression. 


Fig.  150. 


Fig.   151. 
Figs.    150  and   151. — Result   of   oversized   tongue,   which  may   be   congenital. 

Other  congenital  conditions  may  be  large  or  oversized  tongue  (Figs. 
150  and  151),  or  undersized  tongue;  although  the  latter  condition  oc- 


ETIOLOGY   OF    MALOCCLUSION 


139 


curs  very  rarely  and  complete  data  in  any  great  number  of  these  cases 
have  not  yet  been  worked  out. 

In  considering-  inherited,  congenital,  and  acquired  causes  of  maloc- 
clusion, the  time  of  the  appearance  of  the  factors  that  produce  the  mal- 
occlusion must  be  kept  in  mind.  The  individual  is  the  result  of  the 
union  of  the  male  and  female  germ  cells  and  everything  that  is  inher- 
ited is  present  in  the  germ  cells  at  the  time  of  the  union.  After  the 
union  of  the  male  and  female  germ  cells  and  while  the  individual  is 
in  utero  the  congenital  conditions  make  their  appearance,  some  of 
which  are  the  result  of  inherited  conditions  and  some  are  the  result  of 
environment  upon  the  mother.  Such  congenital  conditions  as  are  nor- 
mal are  always  inherited,  hut  a  great  many  of  the  abnormal  congeni- 
tal conditions  are  the  result  of  environment.  After  the  birth  of  the 
individual,  the  acquired  conditions  arise  which  may  aid  in  the  normal 
development  of  the  person,  or  which  may  so  affect  the  body  as  to  pro- 
duce pathologic  conditions  or  developments.      The   effect   of   inherited. 


Male  germ  cell 
Inheritance 
Female  germ  eel  I  - 


■Congenital 


Fertilization 


-AcQuired 


Birth 


Death 


Fig.    152. — Diagram    showing   time 


life    when    inherited,    congenital,    and   acquired    factors    are 
active. 


congenital  and  acquired  conditions  on  the  growth  of  the  body  may  be 
shown  by  a  diagram  in  Pig.  L52.  The  first  part  of  the  diagram  with 
the  two  lines  represents  the  male  and  female  germ  cells,  which  carry 
all  of  the  characteristics  that  will  be  transmitted.  As  the  two  lines 
come  together  at  fertilization,  we  have  the  beginning  of  a  new  indi- 
vidual who  has  all  of  the  characteristics  that  can  be  transmitted,  and 
who  is  now  living  under  a  congenital  condition  that  may  be  normal,  or 
that  may  be  abnormal.  The  environment  of  the  mother  will  influence 
the  growth  of  the  embryo  and  a  great  many  constitutional  conditions 
are  begun  at  this  time  that  will  later  develop  into  malocclusions.  At 
birth,  the  individual  is  thrown  upon  his  own  resources,  and  environ- 
ment affects  him  more  than  it  did  during  the  congenital  and  inherited 
periods.  From  birth  to  death  conditions  may  arise  that  will  have  a 
bearing  on  the  production  of  malocclusion.  As  a  result  of  the  study 
of  this  chart,  it  will  be  seen  that  acquired  factors  are  more  responsible 


140 


PRACTICAL    ORTHODONTIA 


Fig.    153. — Malocclusion   produced   by    early   loss   of   deciduous   incisors. 


Fig.   154. — Early  loss  of  deciduous  lateral  has  allowed  maxillary   central  to  drift  toward  the  right 
side.      Mandibular  lateral   is  nearly   in   contact  with   deciduous   molar. 


ETIOLOGY    OF    MALOCCLUSION  141 

for  the  production  of  malocclusions  than  any  of  the  other  factors,  but 
it  must  be  remembered  that  a  large  number  of  constitutional  condi- 
tions are  the  result  of  congenital  conditions  that  do  not  manifest  them- 


Fig.   155. — Maxillary  canine   out  of  line  because  of  early  loss  of  deciduous  canine. 


Fig.    156. — Mandibular    canine   crowded   labially   because   of   contracted   arch   due   to    early    loss   of 

deciduous  canine. 


142  PRACTICAL    ORTHODONTIA 

selves  until  after  birth.  Such  things  as  faulty  development  or  cell 
metabolism,  as  a  result  of  an  improper  environmenl  <>f  the  mother,  and 
improper  nutrition  of  the  embryo  that  results  from  improper  heallh 
of  the  mother,  must  always  be  considered  in  the  study  of  acquired 
eauses. 

Acquired  Causes. — Acquired  eauses  of  malocelusion  are  those  that 
occur  after  the  birth  of  the  individual.  They  are  the  result  of  the  en- 
vironment in  which  the  individual  lives.  Acquired  causes  may  be 
either  local  or  constitutional.  The  majority  of  conditions  that  pro- 
duce malocclusion  of  the  teeth  come  under  the  head  of  acquired  causes. 


Fig.   157. — Early  loss  of  deciduous  molar  has  allowed  permanent  molar  to  drift   forward. 

Early  Loss  of  the  Deciduous  Teeth 

The  early  loss  of  the  deciduous  teeth  may  be  constitutional,  as,  for 
instance,  when  it  is  associated  with  rickets ;  or  it  may  be  local  when 
caused  by  decay,  or  early  extraction.  Malocclusion  is  bound  to  develop 
regardless  of  whether  the  deciduous  tooth  has  been  lost  as  a  result  of 
local  or  constitutional  conditions.  The  early  loss  of  a  deciduous  incisor, 
above  or  below,  will  produce  a  lack  of  development  in  the  region  of  the 
incisors  (Fig.  153).  The  loss  of  the  force  of  the  approximating  teeth 
will  permit  them  to  drift  together.  The  early  loss  of  a  deciduous  sec- 
ond incisor  will  allow  the  first  incisor  to  drift  toward  the  canine  and 


ETIOLOGY    OF    MALOCCLUSION 


143 


close  the  space,  which  will  result  in  an  impacted  permanent  lateral. 
The  early  loss  of  an  upper  or  lower  deciduous  canine  will  permit  the 
incisor  to  drift  toward  the  side  from  which  the  tooth  is  missing  (Fig. 
154)  until  very  often  the  lateral  incisor  comes  in  contact  with  the  first 
deciduous  molar.  As  a  result,  the  dental  arch  will  be  too  small  to  ac- 
commodate the  permanent  canine,   which  will  appear  as  in  Figs.  If).") 


Fig.   158. 


Fig.   159. 

Figs.    158  and   159. — The  maxillary  molars  have   taken  a  mesial  position   as  a  result  of  the  early 
loss   of   the   deciduous   molar   and   the    premolar   is   impacted   as   shown   in    Fig.    159. 


and  156.  The  loss  of  a  deciduous  molar  will  permit  the  permanent  mo- 
lar to  drift  forward  (Fig.  157).  This  will  result  in  an  abnormal  mesio- 
distal  relation  of  the  first  permanent  molar  and  will  also  often  result 


144 


PRACTICAL    ORTHODONTIA 


Fig.   160. — Loss  of  permanent  molar,  acquired  cause  of  malocclusion. 


Fig.    161. — Loss   of   mandibular   first   molar. 


ETIOLOGY    OF    MALOCCLUSION  145 

in  an  impaction  of  the  premolar  when  it  attempts  to  erupt  (Figs.  158 
and  159).  Given  the  loss  of  any  of  the  deciduous  teeth,  it  is  possible 
to  describe  the  malocclusion  that  will  result  in  a  few  years  from  that 
time. 

Tardy  Eruption  of  the  Permanent  Teeth 

Tardy  eruption  of  the  permanent  teeth  is  an  acquired  character- 
istic that  is  very  often  the  result  of  a  constitutional  disease,  as  rickets ; 
or  it  may  be  the  result  of  a  poor  physical  development  that  prevents 
the  proper  calcification  and  eruption  of  the  teeth.  If  the  deciduous 
teeth  have  been  lost,  either  as  the  result  of  constitutional  disease  or  as 
a  result  of  local  cause,  the  space  that  remains  vacant  by  the  non-erup- 
tion of  the  permanent  tooth  will  be  closed  by  other  teeth  drifting  to- 
ward each  other,  because  of  the  loss  of  the  approximal  contact.  The 
longer  the  permanent  teeth  are  delayed  in  eruption  the  more  compli- 
cated becomes  the  malocclusion. 

Early  Loss  of  the  Permanent  Teeth 

Early  loss  of  the  permanent  teeth  produces  a  large  percentage  of 
malocclusions  found  in  adults,  and  malocclusion  will  result  from  the 
loss  of  any  permanent  teeth  at  an  advanced  age.  The  early  loss  of  the 
first  permanent  molar  (Figs.  160  and  161)  produces  a  malocclusion 
which  is  very  difficult  to  treat, 'which  does  a  great  amount  of  damage 
to  the  occlusion  of  the  teeth.  It  destroys  the  masticating  appara- 
tus of  the  patient,  and  this  is  a  predisposing  factor  to  pyorrhea. 
Malocclusion  is  sure  to  result  irrespective  of  the  age  at  which  the  first 
molar  is  lost;  neither  does  it  make  any  difference  whether  the  lower 
and  upper  molars  are  lost  on  the  same  side  or  on  opposite  sides  (Fig. 
162)  ;  nor  whether  one  or  all  of  them  are  lost.  The  malocclusion  will 
result,  and  result  in  such  a  positive  manner  that  it  is  possible  to  fore- 
tell what  is  going  to  take  place  by  knowing  the  time  at  which  the 
molar  is  lost.  Some  authors  have  advocated  the  extraction  of  the 
first  permanent  molar  for  the  correction  and  prevention  of  malocclu- 
sion, explaining  that  the  second  molar  would  move  forward  and  take 
the  position  occupied  by  the  first  molar.  This  is  a  false  theory,  and 
one  that  has  caused  no  end  of  trouble.  Loss  of  the  lower  first  molar 
permits  the  lower  second  molars  to  tip  forward  half  the  width  of  a 
tooth  (Fig.  163),  and  the  teeth  anterior  to  the  lower  first  molar  will 
drop  back  half  of  the  distance  (Fig.  164),  which  will  destroy  the 
occlusion  on  that  side  of  the  mouth.     In  addition  to  this  malocclusion 


146 


PRACTICAL    ORTHODONTIA 


Fig.    162. — Loss   of   mandibular   and    maxillary    first   molars. 


Fig.   163. — Loss  of  mandibular  first  molar  at  early  age. 


ETIOLOGY    OF    MALOCCLUSION  147 

there  will  occur  an  overlapping  of  the  maxillary  anterior  teeth  and  the 
mandibular  incisors  will  drop  distally  (Fig.  165)  so  far  as  to  occlude 
against  the  gingival  of  the  maxillary  teeth.  The  facial  deformity  that 
is  produced  is  one  in  which  the  chin  is  too  close  to  the  nose  (Fig.  166). 
The  loss  of  both  mandibular  first  molars  would  simply  make  the  maloc- 


Fig.    164. — Malocclusion   produced   by    loss   of  permanent   mandibular   molar. 


Fig.  165. — Excessive  over-bite  produced  as  a  result  of  extraction  of  mandibular  permanent  molars. 


148  PRACTICAL    ORTHODONTIA 

elusion  more  pronounced  and  the  facial  deformity  more  noticeable.  The 
loss  of  all  four  first  molars  would  produce  a  very  similar  type  of  maloc- 
clusion, destroy  the  approximal  contact  of  all  of  the  teeth  and  ruin  their 
masticating  efficiency,  bringing  about  an  inharmonious  expression  of  the 
face.  The  reason  that  the  loss  of  all  four  first  molars  destroys  the  ap- 
proximal contact  point  and  the  facial   expression,   with  a  tremendous 


Fig.   166. — Facial  deformity  caused  by  loss  of  mandibular   first  molar  in   Fig.    163. 

loss  of  masticating  efficiency,  is  because  the  upper  and  lower  first  molars 
have  entirely  different  shapes  and  are  different  in  mesio-distal  diameters, 
and  the  teeth  mesial  and  distal  to  them  tip  as  the  teeth  drift  together. 

The  Loss  of  the  Mesio-Distal  Diameter  of  the  Teeth 

Malocclusion  will  result  in  the  premature  loss  of  the  deciduous  or 
permanent  teeth,  because  the  approximal  contact  of  that  arch  has  been 
destroyed,  which  results  in  a  mesio-distal  shortening  of  that  particu- 
lar lateral  half.  The  loss  of  the  mesio-distal  diameter  of  the  lateral  half 
of  the  arch  is  not  so  great  as  the  loss  of  the  entire  tooth.  The  loss  of 
the  mesio-distal  diameter  of  the  tooth  is  generally  the  result  of  caries 
with  improper  treatment  of  the  same.  A  large  number  of  malocclu- 
sions are  produced  because  of  the  loss  or  decrease  of  the  mesio-distal 
diameter  of  the  deciduous  molars.  It  is  a  well-known  fact  that  the 
deciduous  molars  are  wider  mesio-distally  than  the  premolars.  This 
has  caused  many  to  believe  wrongfully  that  it  is  possible  to  allow  the 


ETIOLOGY    OF    MALOCCLUSION  149 

mesio-distal  diameter  of  the  deciduous  tooth  to  become  less  than  nor- 
mal without  producing  any  serious  effect.  This  is  not  true.  The  loss 
of  a  mesio-distal  diameter  of  a  deciduous  molar  as  a  result  of  caries 
will  always  result  in  the  displacement  of  the  first  permanent  molar. 
If  the  loss  is  still  greater  it  will  result  in  the  impaction  of  the  pre- 
molar. Therefore,  to  avoid  the  loss  of  the  mesio-distal  diameter  of 
deciduous  teeth  it  becomes  necessary  that  the  treatment  he  such  as 
will  retain  the  original  diameter.  They  should  he  filled  with  some 
substance  that  will  maintain  tins  mesio-distal  diameter.  The  tooth 
must  be  restored  to  the  original  shape,  size,  and  proper  contour.  It 
very  often  follows,  in  mesial  or  distal  approximal  cavities  that  have 
been  present  for  some  time  in  molars  and  premolars,  that  the  teeth 
have  drifted  together,  destroying  the  mesio-distal  diameter  of  the  tooth 
and  the  mesio-distal  length  of  the  arch.  As  a  result  of  the  loss  of  the 
mesio-distal  diameter  of  the  teeth,  the  cusps  will  not  occlude  properly 
and  there  will  be  inharmony  in  the  size  of  the  arches. 

Improper  Restoration 

We  have  mentioned  the  loss  of  the  approximal  contact  of  the  de- 
ciduous teeth  which  destroys  the  mesio-distal  diameter  of  the  teeth, 
and  the  same  can  be  said  of  conditions  found  in  the  permanent  teeth. 
We  should  also  call  attention  to  improper  restorations  of  the  teeth. 
Very  often  such  restorations  are  not  properly  made  so  as  to  replace 
the  mesio-distal  diameter,  and  fillings  and  inlays  do  not  always  have 
the  properly  shaped  approximal  contact  point.  The  force  of  the  ap- 
proximal contact  point  is  one  of  the  normal  forces  of  occlusion,  and 
failure  to  properly  restore  contact  is  a  cause  of  malocclusion.  The 
occlusal  surfaces  of  the  teeth  are  not  always  properly  restored,  there- 
by destroying  the  force  of  the  inclined  plane.  A  great  many  cases 
of  malocclusion  are  the  direct  result  of  improper  restoration  of  the 
teeth  as  well  as  improper  occlusal  surfaces  of  crowns  and  bridges. 

Mouth-Breathing 

Mouth-breathing  has  long  been  recognized  as  a  cause  of  malocclu- 
sion, and  is  generally  the  result  of  adenoids.  There  are  other  con- 
ditions that  cause  mouth-breathing,  but  the  large  percentage  in  chil- 
dren is  produced  by  adenoids.  Adenoids  may  be  defined  as  the  hyper- 
trophy of  the  lymphoid  tissue  located  in  the  naso-pharynx.     Lymph- 


150 


PRACTICAL    ORTHODONTIA 


oid  tissue  is  present  in  all  children  and  becomes  the  cause  of  mouth- 
breathing  only  when  it  is  infected  and  congested  to  such  an  extent 
that  it  extends  downward  and  forward  until  it  comes  in  contact  with 
the  soft  palate  and  closes  the  naso-pharynx.  In  some  children  this 
congested  condition  becomes  sufficient  to  produce  an  obstruction  of 
the  nasal  tract  when  lying  down  only.  The  mass  of  lymphoid  tissue 
mentioned  above  is  only  a  part  of  a  continuous  ring  that  encircles  the 
pharynx,  and  is  known  as  the  ring  of  Waldeyer.  OwTing  to  the  ease 
with  which  this  ring  of  lymphoid  tissue  becomes  infected  it  is  also 
known  as  the  vicious  circle.  The  enlargement  of  the  mass  of  lymph- 
oid tissue  in  the  naso-pharynx  posterior  and  above  the  soft  palate, 


Fig.   167.  Fig.    168. 

Figs.    167   and    168. — Facial    deformity   caused    by    mouth-breathing. 


can  only  be  seen  by  the  use  of  reflected  light  and  a  pharyngeal  mir- 
ror. However,  the  clinical  picture  of  the  patient  is  enough  to  prove 
the  presence  of  adenoids  to  one  familiar  with  the  conditions.  The  pa- 
tient has  a  "vacant  stare"  which  is  better  described  as  follows:  the 
upper  lip  is  short;  the  external  nares  undeveloped;  lack  of  develop- 
ment through  the  nasal  region ;  antral  cavities  are  undeveloped,  which 
gives  a  narrow  face ;  mandible  underdeveloped ;  poorly  developed  chin. 
The  eyes  often  appear  large  and  staring,  which  is  the  result  of  lack 
of  development  of  the  nasal  regions.  Figs.  167  and  168  show  the  ap- 
pearance of  a  patient  who  is  a  mouth-breather  as  the  result  of  adenoids. 
Patients  suffering  from  this  condition  all  present  the  same  picture. 
Figs.  169  and  170  show  a  case  somewhat  older.    As  these  patients  grow 


ETIOLOGY    OF    MALOCCLUSION 


151 


older,  the  condition  becomes  more  marked  and  in  adults  the  deformity 
is  great  (Figs.  171  and  172). 

Owing  to  mouth-breathing,  air  does  not  pass  through  the  nasal  cav- 
ities, and  as  a  result  no  pressure  from  the  air  during  inhalation  and 


Fig.   169.  Fig.   170. 

Figs.    169   and    170. — Facial    deformity    of   older   patient   caused   by    mouth-breathing. 


Fig.  171.  Fig.  172. 

Figs.   171  and   172. — Facial  deformity  caused  by  mouth-breathini 


exhalation  is  exerted  upon  the  walls  of  the  nose.  The  relation  of  the 
bony  walls  of  the  nose  is  shown  in  Fig.  173,  made  from  an  embryo  at 
birth.     At  this  age  the  maxillary  sinus  is  not  seen  and  the  roof  of  the 


152 


PRACTICAL   ORTHODONTIA 


mouth  is  nearly  straight.  The  inferior  turbinated  bone  lies  close  to 
the  floor  of  the  nose.  If  the  child  breathes  normally,  the  nasal  cavity 
will  develop,  the  floor  of  the  nose  will  be  carried  downward  and  the  sep- 
tum will  have  room  to  grow.  The  growth  of  the  nasal  cavity  affects  the 
growth  of  the  maxillary  hone,  and  likewise  anything  which  affects  the 
growth  of  the  maxillary  bone  will  influence  the  oral  cavity.  Fig.  174 
shows  the  maxillary  hones,  and  it  will  be  seen  that  about  three-fourths 
of  the  lateral  walls  and  four-fifths  of  the  floor  of  the  nose  is  made  up  of 
the  superior  maxillary  hones.    It  is  therefore  easy  to  understand  how  the 


Fig.    173. — Shape    and    relation    of    nasal    cavity    and    roof   of    mouth    at    birth.      Note    absence    of 

maxillary    sinus. 


lack  of  development  of  the  nasal  cavity  will  influence  the  maxillary  bone 
and  how  the  lack  of  growth  of  the  maxillary  hone  will  influence  the  nasal 
cavity.  As  the  child  grows,  the  nasal  cavity  increases  in  size  and  grows 
downward  and  outward  until  in  the  adult  we  find  conditions  as  shown  in 
Figs.  22  and  175,  the  force  of  air  pressure  during  breathing  acting  as  a 
force  to  cause  the  normal  development  of  the  nasal  and  oral  cavities. 
Muscular  pressure  also  plays  an  important  part.    In  normal  breathers, 


ETIOLOGY    OF    MALOCCLUSION 


153 


the  mandible  is  held  in  place  by  atmospheric  pressure.  When  the  month 
is  closed,  one  usually  swallows,  which  brings  the  tongue  up  against 
the  roof  of  the  month  and  causes  it  to  fill  the  whole  of  the  oral  cavity. 
As  a  result  of  the  tongue  occupying  this  position,  pressure  is  exerted 
on  the  lingual  sides  of  the  upper  and  lower  teeth,  which  forces  them 
buccally.  In  month-breathing,  the  tongue  does  not  exert  any  force  on 
the  upper  teeth,  which  allows  the  upper  arch  to  remain  undeveloped, 
and  it  is  therefore  spoken  of  as  a  narrow  arch.  The  tongue  lies  in  the 
lower  part  of  the  oral  cavity  and  does  not  touch  the  lower  anterior 
teeth.     The  mandible  drops  downward  as  a  result  of  the  loss  of  atmos- 


Fig.    174. — Maxillary    bones,    showing    large    amount    of    nasal    cavity    formed    by    maxillary    bones. 


pheric  presure  and  the  muscles  that  depress  the  mandible  hold  the 
mandible  from  developing  forward,  owing  to  the  weight  that  they  exert 
on  the  anterior  part.  As  the  month  is  held  open,  the  molars  are  sepa- 
rated enough  to  allow  the  mandibular  molars  to  lock  distal  to  the  upper 
molars.  If  mouth-breathing  occurs  early  in  life,  we  find  the  deciduous 
teeth  as  shown  in  Fig.  176,  which  makes  distoclusion  with  labioversion 
of  the  maxillary  anterior  teeth,  or  Class  II,  Division  1,  the  prevailing 
type.  If  month-breathing  occurs  after  the  locking  of  the  first  molars, 
and  the  cusps  of  the  teeth  are  long,  we  find  such  cases  as  are  shown  in 
Fiff.  38. 


154 


PRACTICAL    ORTHODONTIA 


As  the  action  of  the  muscles  is  abnormal,  the  upper  lip  does  not 
exert  pressure  on  the  maxillary  anterior  teeth,  thus  allowing  them  to 
protrude.     With  the  open  mouth  and  parted  lips,  the  lower  lip  drops 


Fig.    175. — Relation    of    nasal    and    oral   cavities    in    the   adult.      Compare    with    Fig.    173. 


hack  against  the  mandibular  teeth  and  then  the  upper  portion  of  the 
lower  lip  exerts  pressure  on  the  lingual  surface  of  the  maxillary  teeth, 
as  shown  in  Fig.  177.  "The  irritation  of  the  maxillary  teeth  causes  the 
lower  lip  to  become  thicker,  which  in  turn  causes  the  maxillary  teeth 
to  protrude  farther. 


ETIOLOGY    OF    MALOCCLUSION 

Enlarged  Tonsils 


155 


Associated  with  the  enlargement  of  the  lymphoid  tissue  in  the  naso- 
pharynx is  the  enlargement  of  the  lymphoid  tissue  in  the  oral  phar- 
ynx, commonly  called  tonsils.  These  masses  of  tissue  are  located  on 
the  right  and  left  sides  of  the  oral  pharynx  at  the  base  of  the  tongue, 


Fig.   176. — Malocclusion   of  deciduous   teeth   caused   by  mouth-breathing. 


Fig.    177. — Showing    abnormal    muscular    pressure    associated    with    mouth-breathing.       (Pollock.; 

between  the  anterior  and  posterior  pillars  of  the  fances.  The  tonsils 
often  become  inflamed  and  are  the  source  of  much  annoyance.  As 
they  are  enclosed  in  a  capsule  and  contain  a  considerable  amount  of 


156  PRACTICAL    ORTHODONTIA 

connective  tissue,  the  tonsils  are  quite  painful  when  they  become  in- 
flamed, in  which  respect  they  differ  from  adenoids.  .Many  times  the 
tonsil  becomes  chronically  inflamed,  and  when  in  that  state  often  is 
the  beginning  of  mesioclusion,  or  (lass  ID  eases.  Owing  to  the  in- 
flamed tonsil,  the  child  protrudes  the  mandible,  which  produces  more 
space  between  the  pillars  of  the  fauces  and  consequently  relieves  the 
pressure  on  the  inflamed  tonsil.  As  a  result  of  the  protruded  man- 
dible the  teeth  are  locked  in  an  abnormal  position.  As  the  muscular 
action  that  moved  the  mandible  forward  is  relinquished,  the  mandible 
drops  back  to  its  normal  position,  but  as  the  teeth  are  locked  in  an 
abnormal  relation  they  remain  in  that  position  and  malocclusion  re- 
sults. 

Habits 

Habits  of  childhood  produce  a  few  types  of  malocclusion.  Thumb- 
sucking  and  finger-sucking  have  long  occupied  a  place  among  the  etio- 
logic  factors  of  malocclusion,  but  they  do  not  produce  as  many  maloc- 
clusions as  was  formerly  supposed.  There  are  a  few  cases  that  are 
produced  by  lip-biting  and  lip-sucking,  also  others  which  are  produced 
by  tongue  habits.  This  type  of  eases  becomes  very  troublesome  to  treat 
unless  it  is  possible  to  break  the  patient  of  the  habit. 

Sore  Teeth 

Very  often  the  decay  of  a  deciduous  tooth  will  cause  the  child  to 
masticate  in  such  a  manner  as  to  miss  that  tooth,  with  the  result  that 
the  mandible  will  be  thrown  to  one  side.  This  will  permit  some  of 
the  teeth  to  lock  abnormally  when  they  are  erupting  and  thus  furnish 
the  starting  point  of  a  severe  malocclusion. 

In  certain  cases,  other  conditions  will  be  found  to  play  a  part  in 
the  production  of  malocclusion.  Each  case  must  be  studied  carefully 
and  every  effort  made  to  find  the  etiologic  factor  that  has  been  re- 
sponsible for  the  deformity. 


CHAPTER  V 
REGULATING  APPLIANCES 

Principles  of  Regulating-  Appliances 

Regulating  appliances  are  mechanical  devices  for  the  purpose  of 
exerting  force  upon  malposed  teeth,  in  turn  creating  cell  activity  and 
thereby  causing  the  teeth  to  assume  a  proper  position  in  the  line  of 
occlusion.  It  is  necessary  that  the  operator  has  a  proper  conception 
of  what  the  regulating  appliance  is  for.  The  appliance  must  be  viewed 
from  three  distinct  angles.  First,  it  is  a  mechanical  device  for  exerting 
force  upon  malposed  teeth,  which  is  thejiecessary  feature.  If  the  ap- 
pliance is  mechanically  imperfect  and  does  not  exert  the  pressure  upon 
the  proper  teeth,  failure  will  result.  The  second  and  equally  important 
point  is  the  purpose  of  the  appliance,  which  is  to  exert_force^ upon,  the 
malposed  teeth  to  ''create  cell  activity.' '  After  the  cell  activity  occurs, 
the  third  factor  of  the  appliance  is  manifested,  which  is  to  exert  pres- 
sure onjhe  malposed  teeth  and  guide  them  into  their  proper  position. 
The  mere  exertion  of  force  upon  the  teeth  is  not  enough  to  cause  them  to 
assume  the  position  in  the  line  of  occlusion  that  they  should  occupy. 
It  is  true  that  teeth  have  been  moved  and  can  be  moved  by  the  appli- 
cation of  a  great  amount  of  force  and  such  movement  occurs  too  often, 
but  the  movement  is  not  physiologic  and  those  who  use  such  methods 
are  not  practicing  orthodontia.  They  are  only  moving  teeth  and  caus- 
ing much  suffering  to  their  patients. 

Requirements  of  Regulating  Appliances 

In  the  definition  of  appliances,  Ave  state  what  the  appliance  is  for 
and  what  it  must  do,  which  arc  the  essential  features  of  any  appli- 
ance. However,  there  are  requirements  that  appliances  must  possess 
and  some  appliances  are  better  suited  to  do  certain  things  and  correct 
certain  types  of  malocclusion  than  others. 

Efficiency. — Efficiency  might  be  named  as  the  first  essential  feature, 
which  means  that  the  appliance  should  do  the  work  for  which  it  was 
devised.  This  may  seem  like  an  extravagant  statement,  yet  formerly 
appliances  have  been  invented  that  were  not  suited  to  do  the  work 
intended.     It  is  possible  to  exert  force  on  teeth  with  very  crude  and 

157 


158  PRACTICAL   ORTHODONTIA 

unscientific  devices  and  accomplish  some  results.  However,  when  we 
speak  of  efficiency,  we  mean  that  the  appliance  should  accomplish  the 
desired  results  without  waste  of  time  or  energy.  The  appliance  should 
he  so  made  that  it  will  follow  certain  mechanical  principles  that  have 
heen  proved  effective  in  other  devices.  After  the  appliance  is  constructed 
along  the  proper  mechanical  lines  which  make  it  an  efficient  device, 
this  efficiency  may  be  lost  and  destroyed  by  insecure  attachments  of  the 
appliance,  either  to  the  malposed  tooth,  or  to  the  anchor  tooth.  As  ex- 
ample, the  jackscrew  is  an  efficient  appliance  so  far  as  the  mechanical 
device  is  concerned,  but  in  a  great  many  cases,  the  efficiency  has  been 
lost,  because  of  insecure  attachments.  There  must  be  some  means  of  at- 
taching the  appliance  to  the  teeth  to  be  moved  so  that  it  will  be  possible 
to  exert  the  required  amount  of  force  and  in  the  proper  direction.  The 
appliance  must  be  attached  to  some  point  that  is  known  as  the  anchor 
tooth,  or  we  may  say  that  the  appliance  must  possess  sufficient  anchor- 
age. As  anchorage  is  one  of  the  essential  features  in  the  efficiency  of 
appliances,  it  will  be  described  under  a  separate  heading. 

Durability. — The  appliance  must  be  so  constructed  that  it  will  be 
capable  of  use  during  the  entire  operation.  It  should  be  of  such  ma- 
terial that  it  will  be  little  affected  by  the  fluids  of  the  mouth,  and  of 
such  design  that  force  can  be  exerted  upon  any  or  all  of  the  teeth 
at  the  same  time  and  in  similar  or  opposite  directions.  By  having  such 
an  appliance  it  is  not  necessary  to  subject  the  patient  to  the  fitting  of 
several  different  appliances  before  the  case  is  completed.  It  saves  much 
time  for  the  operator  and  accomplishes  the  result  in  the  shortest  pos- 
sible time. 

Cleanliness  and  Antisepsis  are  properties  which  go  together  to  a 
certain  extent.  It  must  be  possible  for  the  patient  to  keep  the  teeth 
clean,  which  can  only  be  accomplished  when  the  appliance  is  constructed 
with  that  idea  in  view.  For  example,  round  appliances  are  more  easily 
cleaned  than  flat  appliances,  for  there  is  not  so  much  of  the  appliance 
in  contact  with  the  teeth.  All  bands  must  be  cemented  on  to  prevent 
anything  getting  between  the  teeth  and  the  bands.  The  use  of  cement 
is  for  prophylactic  measures.  In  regard  to  aseptic  appliances,  the  ma- 
terial out  of  which  the  appliances  are  constructed  plays  an  important 
part.  Some  alloy  that  contains  an  amount  of  copper  or  zinc  is  more 
aseptic  than  \gold  or  platinum.  The  use  of  some  of  the  non-corrosive 
alloys  offers  the  advantage  of  being  aseptic  and  at  the  same  time  pre- 
senting a  good  appearance  in  the  mouth. 

Simplicity  is  another  characteristic  that  must  always  be  considered. 
All  mechanical  devices  are  more  useful  as  they  approach  simplicity. 


REGULATING    APPLIANCES  159 

In  fact,  the  only  perfect  mechanical  devices  we  have  are  those  that 
have  eliminated  all  superfluous  parts  until  nothing  remains  that  does 
not  perform  some  definite  function.  The  tendency  in  modern  regulat- 
ing appliances  is  to  eliminate  all  parts  that  do  not  add  greatly  to  the 
value  of  the  appliance.  Appliances  should  he  constructed  so  as  to 
get  the  greatest  number  of  principles  without  increasing  the  bulk.  Many 
devices  constructed  in  former  years  have  failed  because  simplicity  was 
neglected. 

Inconspicuousness  is  a  feature  that  is  considered  only  for  the  satis- 
faction of  the  patient.  This  essential  is  one  that  the  patient  is  always 
considering  and  often  the  success  of  the  practitioner  will  depend  upon 
his  ability  to  make  the  appliance  inconspicuous.  If  cleanliness,  asep- 
tic properties  and  simplicity  have  been  considered  as  they  should  be, 
inconspicuousness  will  generally  follow.  Still,  many  appliances  that 
are  conspicuous  in  the  hands  of  some  operators  look  well  and  are  little 
seen  when  used  by  others.  Experience  has  shown  that  the  expansion 
arch,  which  is  the  most  universal  fixed  appliance,  can  be  made  incon- 
spicuous if  properly  applied  and  at  the  same  time  will  be  just  as 
efficient  as  if  it  were  used  otherwise.  In  no  case  must  efficiency  be 
sacrificed  for  inconspicuousness,  as  when  we  are  often  requested  by 
the  patient  to  place  the  appliance  lingual  to  the  teeth.  Experience 
has  proved  that  a  lingual  appliance  is  less  conspicuous  than  a  labial 
appliance,  but  in  using  a  lingual  appliance,  the  operator  must  be  able 
to  accomplish  results  with  it  that  will  be  equally  as  effective  as  the 
labial  appliance.  Efficiency  must  not  be  sacrificed  for  inconspicuous- 
ness. 

Fixed  and  Removable  Appliances 

Regulating  appliances  are  divided  into  fixed  and  removable.  Fixed 
appliances  are  those  that  are  placed  on  the  teeth  in  such  a  manner 
that  they  can  only  be  removed  by  the  operator.  Removable  appliances 
are  those  that  are  attached  to  the  teeth  in  such  a  manner  that  they  can 
be  removed  by  the  patient. 

Fixed  Appliances  have  the  advantage  of  firm  attachment  both  to 
the  moving  teeth  and  to  the  anchor  teeth.  As  it  is  firmly  attached  the 
appliance  can  be  of  smaller  size  than  if  of  the  removable  variety. 

The  fixed  appliances  may  be  divided  into  the  labial  and  lingual 
arches.  The  labial  arch,  when  used  as  an  ordinary  expansion  arch, 
is  very  conspicuous  and  less  cleanly  than  the  removable  appliance. 
The  same  objection  holds  true  in  regard  to  the  pin-and-tube  appliance, 
the  ribbon  arch,  and  similar  appliances.     The  lingual  arches  are  very 


160  PRACTICAL    ORTHODONTIA 

inconspicuous  and  cleanly  and  offer  many  advantages  that  are  not  pos- 
sessed by  the  labial  arch.  They  have  firm  attachments  and  cause  little 
inconvenience  to  the  patients. 

Removable  Appliances  are  recommended  because  of  the  fact  that 
they  can  be  removed  by  the  patient  and  the  appliance  and  teeth  thor- 
oughly cleaned  after  each  meal.  They  arc  less  conspicuous  than  the 
fixed  labial  appliances,  but  have  the  disadvantage  that  they  are  not 
securely  attached  to  the  moving  teeth  or  to  the  anchor  teeth,  which 
limits  their  use  in  some  of  the  complicated  cases  of  malocclusion.  The 
simpler  forms  of  malocclusion  can  be  treated  with  the  removable  ap- 
pliance, but  there  are  a  large  number  of  cases  in  which  the  results 
obtained  by  the  fixed  appliance  are  better  than  the  author  has  ever 
seen  from  the  treatment  of  similar  cases  by  the  removable  appliance. 
One  of  the  great  advantages  of  the  removable  appliance,  namely,  that 
the  patient  can  remove  it,  becomes  a  disadvantage  in  the  mouths  of 
some  patients. 

Technique  for  Making  Regulating  Appliances 

Various  forms  of  fixed  devices  have  been  placed  on  the  market  and 
used  at  different  times,  some  of  which  have  become  obsolete.  It  is 
the  author's  intention  to  consider  only  those  that  have  a  place  in 
modern  orthodontia,  those  that  he  has  found  of  advantage  and  those 
that  are  employed  by  the  majority  of  men  who  are  devoting  their 
entire  time  to  the  practice  of  orthodontia. 

Bands 

Bands  form  one  of  the  principal  parts  of  the  fixed  appliance.  Bands 
are  divided  into  plain  and  clamp  (Figs.  178  and  210).  A  plain  band 
is  made  by  pinching  or  burnishing  a  piece  of  metal  around   the  tooth 


Fig.    178. — Plain,    or    Magill.    bands. 

to  be  banded  or  around  a  model  of  the  same  and  soldering  the  ends 
together.  The  size  of  the  hand  is  not  adjustable.  They  are  made  and 
used  on  all  of  the  teeth,  but  the  best  fitting  hands  are  made  on  the 
six  anterior  teeth.  Plain  bands  can  be  made  for  molars  and  premolars 
that  fit  very  accurately  if  the  proper  technique  is  followed. 


REGULATING  APPLIANCES  161 

Which  form  of  plain  band  was  first  used,  or  the  inventor  of  same, 
has  never  been  known.  They  did  not  meet  with  universal  use  until 
the  introduction  of  cement.  The  use  and  making  of  the  plain  band 
as  most  employed  today  was  introduced  b}^  Magill,  and  is  known  in  lit- 
erature as  the  "Magill  band." 

Composition  of  Appliances. — The  band  may  be  made  out  of  various 
materials,  namely,  gold,  gold  and  platinum,  iridio -platinum,  nickel  sil 
ver,  and  aluminum-bronze.  There  are  several  alloys  on  the  market  sold 
under  various  names  which  are  said  to  possess  certain  desirable  quali- 
ties. These  alloys  are  probably  aluminum-bronze.  The  "non-corrosive 
material"  sold  by  some  manufacturers  makes  a  very  desirable  material. 
Each  one  of  the  various  materials  used  for  plain  bands  has  its  advan- 
tages and  disadvantages. 

Gold,  which  was  probably  used  first,  is  recommended  for  its  ease 
of  manipulation  and  for  its  color.  It  does  not  tarnish  easily  in  the 
mouth,  although  in  some  instances  it  does  discolor  greatly.  One  of 
the  disadvantages  of  gold  is  the  lack  of  strength  when  rolled  thin 
enough  to  permit  its  use  without  causing  great  separation  of  the  teeth. 
Also,  if  appliances  are  attached  to  gold  bands  and  considerable  force 
exerted  upon  the  appliances  the  gold  will  tear.  Still,  the  greatest  dis- 
advantage to  the  use  of  gold  is  that  it  possesses  no  antiseptic  property. 
Alloys  of  gold  to  form  what  is  known  as  clasp  metal  have  been  used 
which  eliminate  some  of  the  first  objections,  but  the  last  one  still  remains. 
Gold  and  platinum  material,  composed  of  equal  parts  of  gold  and  plat- 
inum, makes  an  alloy  that  is  strong,  can  be  rolled  thin  and  has  a  nice 
appearance,  discolors  in  some  months,  and  is  not  antiseptic,  that  is, 
does  not  retard  the  growth  of  microorganisms.  On  account  of  the  last- 
named  objection  it  is  little  used  by  the  author. 

Iridio-platinum  is  a  material  much  used  by  some  practitioners,  and  is 
very  strong  even  when  rolled  thin.  It  is  seldom  necessary  to  use  it 
more  than  .005  or  36  gauge  and  some  cases  will  possess  sufficient  strength 
when  used  .003  or  40  gauge.  It  melts  at  a  high  degree  of  temperature 
and  can  be  soldered  with  pure  gold.  This  leaves  little  danger  of  the 
opening  of  the  solder-joint  when  other  solder  attachments  are  being 
made  to  the  band.  Also,  the  joint  will  not  open  under  stress  as  some- 
times happens  when  a  low  karat  solder  is  used.  Iridio-platinum  dis- 
colors in  some  mouths  and  like  the  other  noble  metals  does  not  retard 
the  growTth  of  microorganisms.  A  tooth  that  is  in  contact  with  an 
iridio-platinum  appliance  is  very  liable  to  decay ;  in  fact  it  seems  as 
if  the  tooth  is  more  apt  to  decay  than  not.  As  a  result  of  the  use  of  this 
material,  many  caries  have  been  caused  that  would  not  have  been  pro- 


162  PRACTICAL    ORTHODONTIA 

duced  otherwise.  Owing  to  the  great  strength  of  iridio-platinum,  it  is 
the  most  satisfactory  of  all  the  band  materials  from  a  mechanical  stand- 
point. It  is  quite  stiff,  which  makes  it  more  difficult  to  work  than  some 
other  materials,  but  when  properly  adapted  to  the  tooth,  the  stiffness 
becomes  a  mechanical  advantage  as  it  will  stand  the  stress  of  mastica- 
tion without  the  occlusal  edge  bending  as  often  occurs  in  softer  band  ma- 
terials. The  stiffness  of  the  band  material  is  also  an  advantage,  in  forc- 
ing the  band  between  teeth  that  have  a  tight  approximal  contact.  Also 
in  an  iridio-platinum  band  if  properly  contoured,  the  stiffness  will  en- 
able the  band  to  be  so  shaped  that  it  will  pass  over  the  tooth  with  a 
snap  and  hug  the  contour  of  the  tooth  on  the  mesial  and  distal  sides 
which  will  not  occur  with  the  use  of  a  soft  band  material.  Realizing 
the  fact  that  iridio-platinum  has  no  antiseptic  properties,  it  becomes 
more  necessary  in  the  use  of  iridio-platinum  that  the  band  be  made  ana- 
tomically correct,  so  as  to  enable  the  patient  to  keep  the  bands  and  ap- 
pliances properly  cleaned  and  therefore  prevent  decay.  The  lack  of 
antiseptic  properties  in  iridio-platinum  is  the  most  objectionable  feature 
it  possesses,  and  one  which  must  always  be  kept  in  mind  in  using  this 
material.  Because  of  the  large  mechanical  advantages  it  possesses,  it 
is  probably  the  most  ideal  band  material  from  a  mechanical  standpoint. 
Nickel  Silver  has  been  used  in  the  past  in  the  making  of  appliances 
to  a  greater  extent  than  any  other  material.  Various  metals  are  used 
in  alloying  of  the  material,  generally  some  percentage  of  nickel,  copper, 
tin  or  zinc  being  employed,  each  manufacturer  having  his  own  com- 
binations. The  great  advantage  of  nickel  silver  lies  in  its  strength,  as  it 
is  much  stronger  than  gold,  and  even  when  rolled  thin  and  made  pli- 
able by  annealing,  it  will  not  stretch.  It  can  be  soldered  with  a  high 
karat  solder,  as  the  melting-point  is  higher  than  low  karat  golds.  It 
takes  a  high  polish  and  in  some  mouths  holds  the  color  well.  Nickel 
silver  can  be  easily  gold-plated,  but  in  those  mouths  where  discoloration 
occurs  the  plate  does  not  last  long.  It  always  corrodes  and  is  affected 
by  the  fluids  of  the  mouth.  Pits  will  form  in  the  bands  and  in  some 
cases  after  six  months  to  a  year  deep  pits  will  form,  which  finally  per- 
forate the  band.  This  limits  the  time  during  which  a  nickel  silver  band 
can  be  left  in  the  mouths  of  some  patients.  In  spite  of  all  these  ob- 
jections nickel  silver  has  an  advantage  that  is  not  possessed  by  the 
metals  above  mentioned,  namely,  its  antiseptic  properties.  This  metal 
will  discolor  and  the  teeth  become  black,  but  there  is  less  liability  of 
the  occurrence  of  decay  than  if  the  appliance  were  not  there.  The  author 
much  prefers,  to  a  metal  that  invites  caries,  one  that  discolors  but  that 
can  be  kept  clean  with  a  reasonable  amount  of  care,  and  one  that  re- 


REGULATING  APPLIANCES  163 

tards  the  growth  of  microorganisms  and  decay  in  those  months  where 
there  is  a  predisposition  to  caries. 

The  objectionable  characteristic  of  nickel  silver — its  tendency  to  dis- 
color— was  taken  up  by  a  number  of  manufacturers  with  the  result  that 
several  metals  were  placed  on  the  market  that  probably  should  be  called 
aluminum-bronze.  The  author  has  never  employed  aluminum-bronze 
under  that  name,  but  for  the  past  six  years  has  used  the  non-corrosive 
metal  as  sold  by  the  various  dealers,  and  he  finds  that  it  has  all  of  the 
advantages  of  nickel  silver;  is  germicidal,  easy  to  work,  can  be  made 
extremely  pliable  but  is  slightly  more  difficult  to  solder.  The  metal  is 
more  yellow  than  nickc!  silver  and  in  some  mouths  turns  the  color  of 
gold.  It  will  discolor  to  no  greater  extent  than  gold,  gold  and  platinum 
or  iridio-platinum.  In  some  mouths  the  bands  have  a  tendency  to  pit, 
but  this  is  a  slight  objection,  which  is  more  than  offset  by  the  germici- 
dal action. 

Most  of  the  materials  above  mentioned  can  be  bought  in  any  suit- 
able width  and  thickness.  Gauge  36  or  .005  is  the  most  ideal  thickness 
for  all  purposes.  For  the  molar  bands  a  thicker  gauge  may  be  used 
and  for  the  anterior  teeth  one  that  is  thinner  may  be  employed. 

Whatever  material  is  employed  must  be  well  annealed  before  being 
used. 

Band  Technique. — Bands  can  be  made  by  the  direct  or  indirect  meth- 
ods. The  direct  method  consists  in  making  the  band  over  the  tooth  by 
pinching  and  burnishing  a  piece  of  metal  to  fit  the  tooth  and  then  sol- 
dering the  ends  of  the  band  together.  These  bands  are  classified  as 
pinch  bands,  which  are  made  by  pinching  the  cud  of  the  material  to- 
gether and  then  soldering  the  pinched  ends;  or  lap  bands,  which  have 
the  end  of  the  material  lapped  over  and  soldered  together.  The  in- 
direct method  consists  of  making  the  band  over  some  form  of  model, 
which  may  be  a  plaster  model  or  a  metal  model.  Metal  models  are 
made  out  of  low  fusing  metals,  Babbitt  and  Malotte's  metal  and  such, 
or  from  amalgam. 

Direct  Band  Technique. — The  seam  of  the  band  that  is  the  soldered 
joint,  can  be  placed  on  the  lingual  or  labial  side  of  the  tooth.  This 
is  decided  by  the  occlusion  of  the  teeth  and  what  other  attachments 
are  to  be  placed  on  the  band.  It  is  more  convenient  to  make  the 
seam  on  the  labial  side,  and  unless  there  is  some  very  good  reason  for 
not  doing  so,  that  side  is  always  chosen. 

In  making  a  band  for  the  upper  incisor,  it  is  seldom  necessary  to 
separate  the  teeth  previous  to  making  the  band.  By  using  a  38  gauge 
material  it  can  generally  be  passed  between  the  teeth.    A  piece  of  band 


1C4 


PRACTICAL    ORTHODONTIA 


Fig.     179. — Angle's     band-forming     pliers 


Fig. 


180. — Angle's  solder- 
ing  pliers. 


material  slightly  longer  than  is  needed  for  the  band  is  passed  between 
the  teeth  and  the  lingual  portion  is  burnished  close  to  the  tooth.  Trac- 
tion is  made  on  the  free  ends  of  the  band  material  and  while  this  is 
being  clone  the  labial  portion  is  made  to  conform  to  the  tooth  by  plier 
beaks,  the  edges  of  which  come  close  together.     For  that  purpose  there 


REGULATING  APPLIANCES 


165 


are  several  forms  of  pliers  on  the  market,  known  as  band-forming  pliers. 
Those  designed  by  Angle  are  shown  in  Fig.  179.  Case  and  Pnllen  have 
also  designed  excellent  band-forming  pliers.  After  the  band  has  been 
pinched  so  as  to  conform  close  to  the  teeth  at  all  points,  it  is  soldered 
by  holding  the  material  with  a  pair  of  soldering  pliers,  made  of  some 
material  that  conducts  heat  poorly,  and  the  points  are  bent  at  right 
angles  (Fig.  180)  so  as  to  conduct  little  heat  away  from  the  band.  A 
little  flux  is  placed  on  the  inside  of  the  seam  (or  joint),  and  when  heated 
to  the  proper  degree,  a  piece  of  solder  in  wire  form  is  touched  to  the 
seam.     The  use  of  a  solder,  either  silver  or  gold,  in  wire  form  will  be 


Fig.    181. — Using    solder   in    wire    form. 

found  to  be  a  great  convenience,  and  is  used  as  shown  in  Fig.  181.  In 
making  these  bands  it  is  necessary  to  have  a  blowpipe  which  can  be  at 
all  times  under  the  absolute  control  of  the  operator  and  still  leave  both 
hands  free.  After  giving  every  blowpipe  and  method  a  fair  trial,  the 
author  has  reached  the  conclusion  that  the  best  results  can  be  secured 
with  the  Herpath  or  Lane  pipe,  the  air  supply  coming  from  the  mouth 
blowpipe.  There  is  no  objection  to  compressed  air,  but  the  author  has 
secured  better  control  over  his  flame  in  the  "old-fashioned  way." 
Plain  bands  on  the  incisors  should  be  placed  as  far  gingivally  as  pos- 
sible without  infringing  upon  the  gums.  As  a  rule  the  author  does 
not  festoon  the  band,  but  leaves  it  the  same  width  the  entire  circum- 


166  PRACTICAL    ORTHODONTIA 

ference,  as  it  makes  a  stronger  band.  Any  band  is  only  as  strong  as 
its  weakest  point.  Some  orthodontists  trim  the  hand  so  that  it  follows 
the  gnm  line  on  all  sides  of  the  tooth.  Others  trim  it  on  the  approxi- 
mal  side  so  that  it  will  not  interfere  with  the  approximal  contact,  which 
makes  a  neat  but  very  weak  band.  Various  attachments  are  placed  on 
the  bands  for  various  purposes. 

In  making  the  direct  band  with  lap  seam,  some  measure  of  the 
tooth  is  made  at  the  point  of  greatest  circumference.  This  measure- 
ment can  be  easily  made  by  using  the  thin  copper  strips  that  are  used 
in  measuring  teeth  for  crowns  and  are  on  the  market  as  the  Hollings- 
worth  copper  strip.  One  of  these  strips  is  pinched  around  the  tooth 
in  the  same  manner  that  the  pinch  band  is  made,  and  a  strip  of  band 
material  is  cut  a  suitable  length  sufficiently  longer  than  the  measure- 
ment to  enable  one  to  properly  lap  the  ends.  The  ends  are  then  sol- 
dered together. 

Mershon    has    described    the    following   technique    for    making    lap 


Fig.    182. — Impression   for   indirect  band-making,    showing   pieces   of   metal   between   teeth   and   ap- 
proximating  teeth    filled    with    moldine.      (Schroeder.) 

bands  for  the  anterior  teeth.  A  piece  of  band  material  is  carefully 
worked  around  the  teeth  and  the  ends  drawn  with  the  fingers  while 
the  band  material  is  burnished  on  the  lingual  side.  The  material  is 
then  removed  and  the  mesial  and  distal  portions  of  the  band  material 
that  will  be  over  the  mesial  and  distal  contact  points,  or  the  points  of 
greatest  convexity,  is  made  concave  by  using  contouring  pliers  that 
have  one  concave  and  one  convex  beak.  The  band  material  is  again 
passed  around  the  tooth  to  be  banded,  and  it  will  be  found  that  the 
band  material  now  fits  the  tooth  closely  on  the  mesial  and  distal  sides, 
owing  to  the  concavity  that  has  been  produced  by  the  use  of  the  con- 
touring pliers.  The  band  is  now  tightly  pinched  by  the  band-forming 
pliers  and  removed.  One  end  of  the  band  material  is  now  cut  off  at 
one  of  the  pinch  marks.  The  other  end  is  straightened  out  and  cut  off 
sufficiently  far  from  the  pinch  mark  to  leave  enough  lap  to  solder.  The 
ends  are  then  soldered  together  with  a  high-fusing  solder,  and  should 
it  be  desired  to  make  any  other  attachments  to  the  band  in  the  region 


REGULATING  APPLIANCES  167 

of  the  seam,  they  can  be  made  by  using  a  lower  fusing  solder  or  by 
holding  the  seam  together  with  a  pair  of  soldering  pliers  while  the 
piece  is  soldered  to  the  band.  If  any  attachment  is  to  be  made  to  a 
band  that  will  require  the  exertion  of  much  force  on  the  attachment, 
either  from  occlusion  or  from  the  appliance,  it  is  an  advantage  to  make 
the  attachment  on  the  lap  seam,  as  this  is  the  strongest  part  of  the 
band. 

Indirect  Band  Technique. — The  first  step  in  indirect  band-making 
is  to  secure  an  impression  from  which  to  make  the  model  of  the  tooth. 
A  plaster  impression  of  the  tooth  to  be  banded  is  obtained,  and  it 
will  necessarily  include  the  approximating  teeth.  The  approximating 
teeth  are  filled  with  moldine,  and  the  moldine  is  built  up  on  the  mesial 
and  distal  side  of  the  impression  of  the  tooth  to  be  banded  and 
around  the  buccal  and  lingual  gingival  margin  in  such  a  manner  as 
to  increase  the  length  of  the  crown  of  the  tooth  when  the  metal 
model  is  made   (Fig.  182).     This  building  of  moldine  around  the  gin- 


Fig.    183. — Metal   models    of    single    teeth.      Models    of    anterior    teeth    made    with    strip    of    metal 

between   teeth.      (Schroeder.) 

gival  margin  of  the  impression  makes  possible  a  metal  tooth  that  has 
the  gingival  margin  exposed  so  that  the  band  can  be  fitted.  The  fill- 
ing of  the  approximating  teeth  with  moldine  eliminates  them  from  the 
metal  models  and  leaves  only  the  tooth  to  be  worked  on,  without  the 
interference  of  any  approximating  teeth.  If  a  model  is  to  be  obtained 
of  the  anterior  teeth,  incisors,  and  canines,  an  ordinary  plaster  im- 
pression is  obtained  of  the  mouth,  and  in  removing  the  impression,  it 
is  broken  in  as  few  pieces  as  possible.  The  impression  is  waxed  to- 
gether and  every  other  tooth  filled  with  moldine,  and  then  the  im- 
pression is  poured  with  Melotte's  metal.  The  plaster  impression  is 
carefully  removed  from  the  metal  model,  care  being  taken  to  avoid 
breaking  the  impression  into  many  pieces.  The  moldine  is  removed 
from  the  impression  of  the  teeth,  the  impression  is  again  placed  to- 
gether, and  moldine  is  placed  in  the  impression  of  those  teeth  from 
which  the  metal  models  were  made  the  first  time.     The  impression  is 


168 


PRACTICAL    ORTHODONTIA 


Fig.   184. — Thin   copper  band  Fig.      185.— -Impression      of 

trimmed    to    festoon    of   gum.  tooth     in     compound. 


Fig.  186. — Impression  with 
celluloid  strip  wrapped 
around    it. 


Fig.    187. — Impression   invested    in   plaster. 


Fig.    188. — Copper    amal- 
gam  model   of  tooth. 


Fig.    189. — Band   soldered 
with    lap   joint. 


o 


Fig.    190.— Band 
swedged. 


Fig.      191. — Cusp     swedged  Fig.  192. — Band  with  cusp 

for    band.  soldered     and     cut     out     for 

occlusion. 

(Coston.) 


Fig.    193. — Crown    with    tube 
and    lug. 


REGULATING  APPLIANCES 


169 


again  poured  full  of  Melotte's  metal  and  we  now  have  a  model  of  the 
remaining  anterior  teeth.  We  now  have  all  of  the  anterior  teeth  re- 
produced in  metal,  bands  can  be  made  over  them,  the  necessary  at- 
tachments made,  and  the  appliance  tried  on  the  model.  The  metal 
molars  and  a  part  of  the  anterior  teeth  will  be  on  one  model,  which 
will  enable  the  operator  to  make  and  adjust  all  appliances  over  the 
models.  This  plan  of  making  a  metal  model  was  shown  the  author  by 
Dr.  Hoggan.  Another  plan  of  taking  a  plaster  impression,  from  which 
a  metal  model  of  incisor  is  made,  is  to  place  band  material  between  the 
teeth  before  the  impression  is  taken.  These  pieces  of  band  material 
remain  in  the  impression  and  when  the  metal  model  is  made,  the 
pieces  of  band  material  are  removed,  which  leaves  sufficient  space  be- 
tween each  tooth  so  the  band  can  be  fitted,  and  each  tooth  has  the 
proper  mesio-distal  diameter.     (Fig.  183.) 

Amalgam  models   are   made   from   copper   amalgam   by   taking   an 


Fig.    194. — Plaster  model  for  use  in  indirect  band-making.      (Mershon.) 

impression  of  the  tooth  in  modeling  compound.  Separating  wires  are 
placed  on  the  mesial  and  distal  side  of  the  tooth  in  order  to  produce 
enough  separation  so  that  a  piece  of  nickel  silver  or  thin  copper 
can  be  roughly  fitted  around  the  tooth  and  the  ends  soldered  to- 
gether (Fig.  184).  The  mesial  and  distal  gingival  borders  are  fes- 
tooned so  as  not  to  interfere  with  the  gum,  and  the  buccal  and  lingual 
portions  of  the  band  must  come  well  gingivally  on  the  buccal  and 
lingual  side  of  the  tooth.  This  gives  us  a  band  of  nickel  silver  or 
copper  that  is  slightly  larger  than  the  tooth  and  about  twice  the 
length  of  the  crown  of  the  tooth.  This  band  is  to  serve  as  an  impres- 
sion tray  and  is  filled  with  modeling  compound  and  forced  over  the 
tooth  (Fig.  185).  This  gives  us  an  impression  of  the  crown  of  the 
tooth  that  is  as  accurate  as  is  possible  to  obtain.  In  order  to  increase 
the  length  of  the   gingival  portion  of  the  impression  and  to   give   a 


170 


PRACTICAL    ORTHODONTIA 


base  to  the  amalgam  tooth,  a  piece  of  celluloid  is  wrapped  around  the 
impression  (Fig.  186).  This  impression  is  then  invested  in  plaster  in 
order  In  give  a  firm  base  in  which  to  pack  the  copper  amalgam  (Fig. 
187).     Copper  amalgam  is  then  packed  into  the  impression,  and  after 


Fig.   195. — Model  with  tooth  trimmed  for  indirect  band  technique.      (Mershon.) 


Fig.    196. — Buccal   view   of   model   for    indirect   band    technique.       (Mershon.) 


Fig.    197. — Wire    measurement    of    tooth    shown   in    Figs.    195    and    196.      (Mershon.) 


it  is  hard  the  plaster  is  broken  apart  and  the  metal  tooth  removed 
(Fig.  188).  Around  this  metal  tooth  a  band  is  made,  with  either  a 
lap  joint  or  a  pinch  joint.  The  lap  joint  is  the  better,  owing  to  the 
fact  that  this  band  is  to  be  swaged,  as  are  all  bands  that  are  made 


REGULATING   APPLIANCES 


171 


over  single  metal  teeth.  The  band  is  fitted  to  the  metal  tooth  and 
placed  in  a  crown  and  bridge  swager  of  the  plunger  type.  A  rubber 
disk,  moldine  or  warm  modeling  compound  may  be  used  as  the  swag- 
ing material.  The  band,  after  being  swaged,  is  shown  in  Fig.  190. 
On  deciduous  molars  and  teeth  that  are  badly  broken  down,  a  cusp 
(Fig.  191)  can  be  swaged  over  the  amalgam  tooth  and  attached  to  the 
band,  which  will  give  a  crown  that  will  offer  more  adhesion  to  the 


Fig.    19S. — Wire   measurement  laid   on   band  material.      (Mershon.) 

cement  and  afford  better  protection  to  the  tooth.  If,  after  cementing 
the  band  in  place,  the  cusp  portion  interferes  with  the  occlusion,  the 
interfering  parts  can  be  ground  off,  leaving  the  band  as  shown  in 
Fig.  192.  Fig.  193  shows  the  buccal  tube  attached  to  the  band.  It 
will  be  noticed  that  there  is  a  small  piece  of  wire  soldered  on  the 
lingual  side  of  the  band,  which  is  for  the  purpose  of  catching  an  in- 
strument under  the  band  to  remove  the  band  from  the  tooth,  in  case 


Fig.      199-A. — Band     material      with 
ends  lapped.      (Mershon.) 


Fig.       199-B.  —  Band      soldered. 
(Mershon.) 


the  band  is  put  on  the  tooth  before  being  cemented.  These  swaged 
bands  fit  more  accurately  than  bands  made  by  any  other  method. 
They  go  on  the  teeth  with  a  snap  and  are  very  difficult  to  remove  even 
if  not  cemented  on  the  teeth.  Bands  that  are  made  over  metal  models 
can  also  be  adapted  by  the  use  of  a  horn  mallet  in  the  same  manner 
that  metal  plates  are  worked  over  a  metal  die.  Bands  can  also  be 
made  by  the  indirect  method  over  plaster  teeth.  A  modeling  com- 
pound impression  is  taken  of  the  teeth  on  one  side  only  in  order  to 


172 


PRACTICAL    ORTHODONTIA 


avoid  drawing  of  the  compound.  A  model  so  made  is  shown  in 
Fig.  194.  With  a  small  saw,  the  teeth  on  the  proximal  sides  of  the 
tooth  to  be  handed  are  cut  away  and  the  model  trimmed  as  shown  in 
Figs.  195  and  196.  A  wire  measure  is  then  taken  of  the  plaster  tooth 
as  shown  in  Figs.  195  and  196.  This  measure  is  taken  at  the  point 
of  greatest  circumference  and  is  twisted  tight  around  the  tooth,  and 
then  the  ends  are  pulled  and  given  one-quarter  or  one-half  more  of  a 
turn.    The  wire  measure  is  then  removed  and  cut  as  shown  in  Fig.  197. 


-a 


Fig.    200. — Mershon's    band-stretching    pliers.       (Mershon.) 

The  measure  is  then  laid  on  a  piece  of  band  material  as  shown  in  Fig. 
198,  the  ends  of  the  band  material  having  been  cut  on  a  bias.  The 
wire  measure  is  placed  on  the  wide  portion  of  the  band  material  and 
a  scratch  is  made  at  the  end  of  the  wire  measure.  The  band  material 
is  cut  about  8-100  of  an  inch  longer  than  needed,  so  as  to  allow  for 
the  overlapping  ends.     The  ends  are  overlapped  far  enough  to  cover 


Fig.    201. — Rand   cut    to    show   effect   of   contouring  and   stretching.      (Mershon.) 

up  the  scratch  on  the  band  material,  for  it  is  desired  that  the  band 
be  made  slightly  smaller  than  the  measurement.  Fig.  199-A  shows  the 
end  of  the  strip  of  band  material  overlapped  preparatory  to  solder- 
ing. Fig.  199-B  shows  the  edges  of  the  band  material  soldered  together. 
The  band  is  then  shaped  to  the  tooth.  In  attempting  to  place  it  on 
the  tooth,  it  will  be  found  to  be  too  small,  owing  to  the  fact  that  the 
occlusal  part  was  made  smaller  than  the  measure.  By  carefully 
noting  where  the  band  binds,  it  can  be  removed  and  pinched  with 


REGULATING  APPLIANCES 


173 


the  band-stretching  pliers  and  again  tried  on  the  tooth.  The  band 
will  now  go  on  farther  than  it  did  before  it  was  stretched.  By  re- 
peating the  trying  on  and  stretching  process,  the  band  can  be  made 


Fig.    202. — Band    with    half-round    tube    attached.       (Mershon.) 

to  fit  the  plaster  tooth  very  accurately.     The  gingival  edges  on  the 
mesial   and  distal  portions  are  trimmed  to   avoid  injury  to  the   gum 


Fig.  203. 


Fig.   204. 
Figs.  203  and  204. — Band   fitted  to   model   of  maxillary   molar.      (Mershon.) 

tissue.  The  stretching  pliers  are  shown  in  Fig.  200.  After  the  band 
has  been  stretched  and  trimmed,  it  will  fit  the  convexities  of  the 
tooth  very  accurately.     If  a  band  so  shaped  is  cut  opposite  to  the 


174 


PRACTICAL    ORTHODONTIA 


seam,  1  lie  band  material  will  have  assumed  a  shape  as  shown  in  Fii>;. 
201. 

In  making'  a  band  after  the  above  technique,  the  seam  on  the  band 
for  the  lower  molar  is  placed  on  the  buccal  side,  and  on  the  band  for 
the  upper  molar  is  placed  on  the  lingual  side.  This  is  because  of  the 
convexity  of  the  respective  surfaces  of  the  maxillary  and  mandibular 
molars.  After  the  band  has  been  fitted  to  the  model,  whatever  at- 
tachment is  necessary  is  placed  on  the  band.  Fig.  202  shows  a  half 
round  spur  that  is  placed  on  the  band  for  use  with  the  removable  lin- 
gual alignment  wire.     If  a  buccal  tube   is  required,   it  can  also  be 


Fig.   205. — Manner  of  holding  wire   to  make  spur  on   plain   band. 

used.  Owing  to  the  fact  that  the  band  is  made  with  a  lap  seam  that 
is  soldered  with  a  high  fusing  solder,  the  tubes  or  any  other  attach- 
ment can  be  made  directly  over  the  soldered  seam.  Any  possibility 
of  opening  up  of  the  seam  can  be  avoided  by  holding  the  lap  ends 
of  the  seam  with  a  pair  of  soldering  pliers  the  ends  of  which  are 
bent  at  right  angles. 

Fig.  203  shows  the  lingual  side  of  a  band  fitted  to  the  model  of  the 
upper  molar.  Notice  how  the  lingual  side  follows  the  convexity  of 
the  lingual  surface  of  the  upper  molar.  Fig.  204  shows  the  occlusal 
view  of  the  same  tooth. 


REGULATING  APPLIA  X  ( !ES 


175 


Soldering  Technique. — A  small  spur  is  soldered  on  the  band  for 
rotating  teeth  and  is  made  as  follows : 

The  spur  should  he  attached  at  a  point  far  enough  gingivally  so 
that  the  ligature  will  pass  above  the  gum  and  below  the  approximal 
contact  point,  and  slightly  to  the  side  toward  which  the  tooth  is  to 
be  rotated.  A  piece  of  wire  of  18  or  20  gauge  is  selected  and  the  end 
filed  to  an  angle  of  45  degrees.  The  band  is  held  in  the  pliers  and  the 
solder  flowed  at  the  point  to  which  the  spur  is  to  be  attached.  This 
is  done  by  heating  the  band  and  touching  it  with  the  wire-solder 
when  it  reaches  the  proper  heat.    A  little  flux  is  placed  on  the  wire 


Fig.  206. — Manner  of  holding  small  tube  on  ligature  wire  while  soldering  same   to  band. 


and  then  by  holding  the  piece  as  shoAvn  in  Fig.  205  the  wire  is  sol- 
dered to  the  band.  The  wire  is  then  cut  off  making  a  spur  about  one 
and  a  half  times  as  long  as  the  thickness  of  the  ligature-wire,  or  liga- 
ture that  is  to  be  used.  In  place  of  the  spur,  Brady  has  suggested 
the  use  of  small  tubes  soldered  well  toward  the  gingival  portion  of 
the  band,  through  which  the  ligature  is  passed.  When  threaded 
through  the  tube,  the  ligature  will  be  prevented  from  coming  off  if  it 
should  in  any  way  become  loose  on  account  of  the  tooth  moving  a 
great  deal  between  visits.  Care  must  be  taken  in  soldering  the  tube 
to  the  band  to  prevent  the  solder  from  flowing  into  the  tube  and 
closing  it.    It  is  held  and  soldered  to  the  band  as  shown  in  Fig.  206. 


176  PRACTICAL    ORTHODONTIA 

The  plain  band  is  also  used  when  the  perpendicular  tube  is  em- 
ployed in  the  bodily  movement  of  teeth  as  suggested  by  Angle.  In 
those  cases  the  seam  of  the  band  is  generally  made  on  the  lingual 
side  as  a  matter  of  convenience. 

The  making  of  the  canine  band  is  more  difficult  owing  to  the  pointed 
shape  of  the  tooth.  A  piece  of  the  band  material  is  placed  between 
the  teeth  and  traction  is  made  on  the  material.  It  will  be  seen  that 
the  occlusal  portion  of  the  material  on  the  lingual  side  stands  away 
from  the  tooth.  While  traction  is  being  made  on  the  ends  of  the  band 
material,  the  lingual  portion  of  the  material  is  pinched  with  the  band- 
forming  pliers,  making  a  pinch  as  shown  in  Fig.  207.  The  material 
is  then  removed  from  the  tooth  and  flux  is  placed  on  the  lingual  portion 
of  the  pinched  baud  material  and  heat  is  applied  and  the  band  is 
touched  with  the  solder  at  the  proper  time.  It  will  now  be  found  that 
the  lingual  portion  of  the  material  fits  the  canine  accurately.  The  me- 
sial and  distal  part  of  the  band  material  that  will  be  against  the  con- 


Fig.   207. — Band   pinched    on   lingual    and   labial   sides. 

vexity  of  the  mesial  and  distal  portion  of  the  tooth  should  be  made  con 
vex,  after  the  method  suggested  by  Mershon,  by  using  a  pair  of  con- 
touring pliers  that  have  a  concave  and  convex  beak.  After  the  mesial 
and  distal  sides  are  made  concave,  with  the  concavity  toward  the  center 
of  the  band,  the  material  is  placed  around  the  canine  and  the  pinch 
is  made  on  the  labial  side.  If  a  pinch  band  is  to  be  made,  it  is  soldered 
in  the  usual  manner,  and  if  lapped,  the  same  technique  is  employed  as 
described  in  the  description  of  making  incisor  bands. 

In  making  plain  bands  for  the  premolars  and  molars,  it  is  best  to 
slightly  separate  those  teeth,  which  enables  us  to  get  the  material  be- 
tween the  teeth  more  easily  and  also  to  secure  a  better  fit,  which  is 
greatly  to  be  desired,  for  it  will  require  long  experience  before  one 
is  able  to  make  a  plain  band  on  the  molars  and  premolars  that  will  in 
any  manner  nearly  approach  the  neatness  of  the  anterior  bands.  The 
best  method  of  producing  separation  is  to  take  a  piece  of  ligature 


REGULATING  APPLIANCES  177 

wire  of  about  26  gauge  and  pass  it  between  the  teeth  gingivally  to 
the  proximal  contact  point  and  bring  the  end  occlusally  to  the  contact 
point  and  twist  the  ends  together.  The  twisting  of  the  ends  exerts 
pressure  upon  the  teeth  and  slightly  separates  them.  One  of  these 
wires  should  be  placed  on  the  mesial  and  distal  side  of  the  tooth  to  )><' 
banded.  Some  have  suggested  the  tying  of  silk  ligature  or  traction 
cable  in  the  same  manner  as  the  wire  ligature  is  placed,  but  the 
author  does  not  like  it  so  well,  for  it  becomes  filthy  and  often  makes 
the  proximal  gum  tissue  sore.  The  wire  ligature  will  produce  suf- 
ficient space  in  twenty-four  hours,  but  no  harm  will  result  if  left  a 
longer  time.  In  making  a  band  for  a  molar  or  premolar,  the  mate- 
rial is  passed  around  the  tooth  and  the  pinch  is  made  at  the  mesio- 
buccal  angle  so  as  to  bring  the  seam  as  near  the  proximal  contact  as 
possible.  This  places  the  soldered  part  of  the  band  out  of  the  way 
of  the  cheek.  As  the  gingival  part  of  the  permanent  molars  and  pre- 
molars is  of  a  smaller  diameter  than  that  part  at  the  contact  points, 
care  must  be  exercised  not  to  pinch  the  band  too  tightly  at  the  gingival 


Fig.    208. — Plain    molar    bands    with    tubes.  Fig.     209. — Plain    band    with     lingual    bar. 

Plain   bands   are   fitted  and   contoured   to   the   tooth. 

portion  or  it  Mill  be  impossible  to  get  the  band  on  the  tooth  after  it 
is  soldered.  After  the  band  is  soldered  it  is  then  placed  on  the  tooth, 
and  if  made  for  the  premolar,  the  mesial  and  distal  occlusal  margins 
are  burnished  into  the  mesial  and  distal  parts  of  the  central  fossa. 
If  made  for  a  molar,  the  disto-occlusal  part  is  burnished  into  the 
distal  part  of  the  central  fossa  of  the  lower  molars  and  into  the  distal 
part  of  the  disto-lingual  fossa  of  the  upper  molars.  This  prevents  the 
band  from  being  forced  too  far  gingivally,  should  the  cement  become 
loosened  between  visits.  It  will  usually  be  necessary  to  make  a  pinch 
on  the  linguo-occlusal  margin  of  the  upper  molars  so  that  the  band  will 
fit  the  convexity  of  the  lingual  surface.  A  pinch  is  often  made  on  the 
buccal  side  of  the  lower  molar  for  the  same  purpose. 

When  this  band  is  made  to  be  used  as  an  anchor  band  with  the 
expansion  arch,  the  band  is  placed  on  the  tooth  after  it  has  been 
burnished  and  the  pinches  soldered,  and  a  scratch  is  made  on  the 
buccal  side  showing  the  proper  direction  in  which  the  tube  is  to  be 


178  PRACTICAL   ORTHODONTIA 

placed.  The  seam  of  the  band  is  held  with  a  pair  of  pliers,  the  point 
of  which  lias  a  groove  of  sufficienl  width  to  straddle  the  seam,  and 
possesses  a  slide  on  the  handle  thai  holds  the  beaks  together.  With 
this  form  of  pliers  the  band  can  be  securely  held,  and  should  there 
be  enough  heat  on  the  band  to  melt  the  solder,  the  seam  will  not  open. 
Solder  is  flowed  on  the  buccal  tube  that  is  to  be  attached  to  the 
band,  flux  is  placed  on  the  band,  and  the  tube  soldered  to  the  band  at 
the  proper  place  and  in  the  proper  direction.  A  band  of  this  kind 
is  shown  in  Fig.  208. 

It  is  much  easier  to  make  a  plain  band  for  the  deciduous  molars, 
because  the  gingival  margin  of  the  teeth  presents  a  diameter  nearly 
as  great  as  any  other  part.  The  band  can  be  pinched  tight  around  the 
tooth,  and  any  free  portion  of  the  band  that  exists  around  the  occlusal 
portion  can  be  burnished  and  pinched  to  the  tooth.  All  pinches  are 
united  with  solder  as  was  done  in  the  canine  bands.  Plain  bands  on 
molars  possess  the  advantage  that  they  do  not  present  any  sharp  por- 
tion on  the  lingual  side,  which  is  a  great  advantage  in  the  case  of 
children.  In  those  cases  in  which  the  permanent  molar  region  re- 
quires expanding  and  the  bands  are  placed  on  the  second  deciduous 
molars,  a  lingual  bar  is  soldered  to  the  band  to  engage  the  first  per- 
manent molar  and  the  first  deciduous  molar.  This  style  of  attachment 
is  shown  in  Fig.  209. 

Plain  molar  and  premolar  bands  are  also  used  in  retaining  appliances. 

Adjusting"  Clamp  Bands. — Clamp  bands  are  made  adjustable  by 
means  of  a  screw  attachment.  There  are  two  kinds  of  clamp  bands, 
those  with  the  clamping  device  on  the  lingual  side  and  those  with  the 
clamping  device  on  the  buccal  side,  as  shown  in  Fig.  210.  Each  style 
of  band  has  advantages  that  will  be  taken  up  separately.  Clamp 
bands  are  made  out  of  German  silver,  "non-corrosive"  metal  "alumi- 
num-bronze," gold  and  platinum,  and  iridio-platinum.  The  author 
prefers  the  band  made  out  of  a  "non-corrosive"  alloy  that  contains 
some  copper. 

The  clamp  band  with  the  clamping  device  on  the  lingual  side,  which 
was  and  is  a  part  of  the  "Angle  appliances,"  makes  the  strongest  and 
best  fitting  clamp  band  known.  It  is  adjustable  to  all  cases  and  by 
changing  the  angle  and  position  of  the  tube,  which  is  in  no  way  a 
part  of  the  clamping  device,  has  a  universal  use.  It  is  now  made  by 
different  manufacturers  in  two  forms,  contoured  and  non-contoured. 
In  order  that  a  contoured  band  be  of  the  greatest  service  it  must  be 
made  for  the  right  and  left  upper  molars  and  for  the  right  and  left 
lower  molars.     A  band  that  is  contoured  is  also  usually  festooned, 


REGULATING  APPLIANCES  179 

which  weakens  the  device.  In  other  words,  ease  of  adaptability  is 
obtained  at  the  expense  of  strength,  but  in  most  cases  the  contoured 
band  is  strong  enough.  The  non-contoured  band  is  universal — can  be 
used  on  either  the  upper  or  the  lower  molars.  It  is  contoured  by  the 
operator  so  as  to  tit  the  individual  tooth.  If  the  band  is  to  be  placed 
on  the  right  upper  molar,  the  screw  should  be  bent  so  as  to  conform 
to  the  convexity  of  the  lingual  surface  and  the  band  contoured  to  the 
shape  of  the  tooth.  The  gingival  portion  of  the  band  should  be  con- 
toured toward  the  center  of  the  tooth  so  that  the  band  will  hug  the 
tooth  and  pass  under  the  gum  and  not  infringe  on  the  gingival  tissue. 
The  band  should  be  placed  about  two-thirds  of  the  way  on  the  tooth 
and  then  tightened  enough  to  make  it  conform  to  the  tooth,  which 
also  makes  the  gingival  portion  bug  the  tooth  closely.  At  this  stage 
of  the  operation  never  tighten  the  band  to  its  fullest  extent  or  it  will 
surely  be  ruined.  Now  loosen  the  band  and  push  it  on  the  rest  of 
the  way.  If  there  is  any  pain  in  putting  on  a  clamp  band,  the  tech- 
nique is  wrong,  or  the  band  is  so  wide  that  it  is  infringing  upon  the 
sum  tissue.     If  the  band  is  too  wide  it  should  be  trimmed  slightly  on 


Fig.   210. — Clamp  bands  with   clamping  device  on   buccal   and  lingual   sides. 

both  the  occlusal  and  the  gingival  side,  taking  off  a  small  portion 
around  the  entire  band.  Never  trim  the  band  only  in  the  proximal 
part,  for  if  that  is  done  the  band  will  be  weakest  at  that  point  and 
probably  tear.  The  object  of  trimming  the  band  on  both  the  occlusal 
and  the  gingival  parts  is  to  cause  the  screw  to  always  pull  from  the 
middle  of  the  band  and  to  make  the  band  draw  evenly  around  the 
tooth.  These  bands  are  made  of  a  material  that  is  thin  and  tough 
enough  so  that  they  will  stretch  over  the  greatest  convexity  and  pull 
into  the  concavities  of  the  mesial  and  distal  gingival  parts.  As  the 
final  tightening  proceeds,  the  band  is  burnished  to  the  teeth  at  all 
parts  that  can  be  reached  with  a  burnisher. 

In  adjusting  a  clamp  band,  with  the  screw  on  the  lingual  side,  care 
must  be  taken  that  the  screw  lies  close  to  the  lingual  surfaces  of  the 
teeth.  Also  the  flat  side  of  the  nut  must  always  be  toward  the  tongue  ; 
never  leave  the  screw  and  nut  projecting  into  the  mouth.  Greater 
care  should  be  exercised  in  having  the  screw  and  nut  in  the  proper 
place  than  in  getting  the  tube  to  occupy  its  proper  position,  for  the 


180 


PRACTICAL    ORTHODONTIA 


lube  can  be  unsoldered  and  placed  a1  the  required  position,  while  the 
screw  can  no1  be  so  treated.  If  the  screw  is  placed  as  suggested,  it 
will  produce  little  annoyance  to  the  patient.  A  band  placed  on  the 
teeth  as  described  will  stay  without  cement,  but  cement  is  used  as  a 
prophylactic  measure  only.  A  clamp  band  that  depends  upon  the 
cement  to  hold  it  on  the  tooth  is  a  poorly  fitted  or  constructed  band. 
The  second  form  of  (damp  band  is  one  that  has  the  (damping  device 
on  the  buccal  side.     The  idea  of  such  a  band  is  to  avoid  having  any- 


Fig.    211. — Hand    with    clamping    device    ami    tube    combined    on    buccal    side.      (I<ukens.) 


Fig.   2\2. — "Arlux"   band   designed  by  Dr.    F.   C.    Rogers. 


thing  on  the  lingual  side  to  annoy  the  tongue.  The  angle  of  the  tube 
cannot  be  changed,  thus  limiting  the  use  of  the  band  in  a  great  num- 
ber of  cases. 

One  form  of  this  band  is  shown  in  Fig.  211.  This  type  of  band  has 
been  improved  by  Rogers  by  placing  a  locking  device  on  the  arch  and 
band  in  such  a  manner  as  to  add  no  extra  bulk  to  the  band,  yet  to  lock- 
securely  the  arch  in  the  tube  of  the  band.  Fig.  212  illustrates  such  a 
band.     In  Fig.  212,  a  shows  the  screw  tube  on  the  band  that  has  the 


REGULATING   APPLIANCES  181 

mesial  end  of  the  outside  of  the  nut  threaded  (&)  to  receive  the  nut  (d), 
which  is  large  enough  to  slip  over  the  nut  (c),  which  is  the  nut  on  the 
alignment  wire,  and  to  screw  on  to  the  threads  on  the  tube  shown  at  b. 

Ligatures 

Ligatures  constitute  one  of  the  important  parts  of  the  fixed  appli- 
ance. Ligatures  are  of  four  kinds — wire,  rubber,  catgut,  and  silk,  or 
grass-line.  Of  the  last  there  are  several  kinds  of  ligatures  on  the  mar- 
ket made  by  different  manufacturers  that  are  very  nearly  the  same. 
They  are  made  of  a   material  that  shortens  under  the  action  of  mois- 


Fig.  213. — Left  central  shows  method  of  looping  silk  ligature  to  rotate  distal  corner  of 
teeth  labially.  Right  central  shows  how  the  ligature  is  then  tied  to  arch  to  rotate  distal 
corner   labially. 

ture  and  continues  to  exert  a  force  on  the  teeth  for  a  considerable  length 
of  time.  The  disadvantage  of  this  ligature  is  that  it  becomes  very 
filthy  owing  to  the  fact  that  it  absorbs  the  fluids  of  the  mouth.  Great 
care  must  be  taken  to  keep  it  away  from  the  gum  1  issue,  bceause  in- 
flammation will  result  if  it  should  come  in  contact  with  the  tissue  at 
any  point.  These  ligatures  are  found  very  useful  in  rotating  teeth, 
for  they  can  be  used  without  a  plain  band.  A  loop  is  made  and  the 
ligature  is  doubled  around  the  tooth,  and  then  both  ends  are  pulled 
tight  and  passed  between  the  teeth  and  tied  around  the  arch.  Fig. 
213  shows  the  manner  of  looping  the  ligature  around  the  tooth,  while 
the  right  central  shows  the  manner  of  pulling  the  ligature  between 


182 


PRACTICAL    ORTHODONTIA 


the  teeth  and  tying  it  around  the  arch.  -lust  before  pulling  the  liga- 
ture tight  around  the  tooth,  J.  Lowe  Young  has  recommended  that  one 
of  the  ends  of  the  ligature  he  passed  through  the  loop,  making  a  wrap 
that  will  prevent  the  loop  from  loosing  as  the  ends  are  being  tied 
around  the  alignment  wire. 

Rubber  Ligatures  are  really  rubber  hands.  They  have  the  greatest 
use  in  intermaxillary  anchorage.  If  used  on  single  teeth  with  intra- 
maxillary  anchorage,  they  exert  too  much  force.  These  ligatures  can 
he  secured  prepared  for  this  purpose,  or  can  be  made  by  cutting  pure 
gum  rubber  tubing  (Fig.  214)  the  desired  length  and  thickness.  The 
length  of  the  ligature  can  be  varied  by  cutting  straight  across  or  on 
the  bias.  Fig.  215  shows  a  length  of  the  rubber  tubing  and  several 
ligatures  all  different  lengths  cut  from  the  same  tube. 

Wire  Ligatures,  as  introduced  by  Angle,  are  very  useful  with  the 


Fig.    214. — Rubber   tubing   from   which   ligatures    of   different   sizes   may    be    cut. 


o 


Fig.   215. — Three  lengths   of   rubber   ligatures  cut   from   tubing   shown   in   Fig.   214. 

fixed  regulating  appliance  that  exerts  both  spring  and  screw  force. 
The  wire  ligatures  are  generally  of  a  tenacious  variety  of  brass, 
although  nickel  silver,  and  iridio-platinum  have  been  used  by  some. 
The  requirements  of  a  Rood  wire  Ligature  are:  softness,  so  that  it  will 
be  easily  adaptable,  and  strength,  so  that  it  will  not  stretch  when 
stress  is  placed  on  it.  They  are  made  in  several  sizes  in  order  that 
they  can  be  easily  passed  through  the  approximal  space  between  the 
contact  points  and  the  gum.  A  ligature  that  is  passed  around  the 
tooth  and  twisted,  as  shown  in  Fig.  216,  is  called  a  plain  ligature.  The 
wire  that  is  on  the  distal  side  of  the  tooth  should  always  be  placed 


REGULATING  APPLIANCES 


183 


gingivally  to  the  arch,  as  there  is  greater  danger  of  slipping  off  on  the 
distal  side  than  on  the  mesial  side.  If  there  is  a  great  tendency  for 
the  ligature  to  slip  off  the  tooth,  the  wire  should  be  passed  between 
the  teeth  on  the  mesial  side  of  the  tooth  toward  the  lingual;  brought 
toward  the  labial  on  the  distal  side  of  the  tooth,   occlusally  to  the 


Fig.    216. — Showing   plain    wire    ligature. 


Fig.    217.— Wire    wrapped    around    teeth    before    being   put    over    arch    to    prevent    ligature    from 

slipping  off. 


18-4  PRACTICAL   ORTHODONTIA 

arch;  through  on  the  mesial  side,  occlusally  to  the  arch;  and  then 
out  on  the  distal,  gingivally  to  the  arch.  This  makes  a  wrapping  of 
the  wire  around  the  tooth  that  grips  it  tight,  besides  the  two  ends 
that  pass  over  the  arch.  This  plan  of  applying  the  ligature  is  shown- 
in  Fig.  217.  When  the  wire  ligature  is  used  to  rotate  a  tooth,  a  plain 
band  that  has  a  tube  or  spur  soldered  on  it  must  be  employed.  Then 
the  ligature  is  passed  between  the  teeth  above  the  arch,  passed  around 
the  spur  on  the  occlusal  side  and  next  brought  through  the  approx- 
imal  space  below  the  arch.     The  reason  for  crossing  the  ligature  on 


Fig.   218. — Wire  wrapped  around  arch   in  front  of  spur  to  prevent  wire  from   slipping  over   spur. 

the  lingual  side  is  that  it  grips  the  spur  more  securely.  If  a  tube  is 
used  on  the  band  instead  of  the  spur,  there  would  be  no  need  of  cross- 
ing the  ligature. 

When  twisting  a  wire  ligature  it  should  always  be  toward  the  right, 
the  same  as  a  nut  is  tightened.  This  will  be  found  very  convenient, 
as  it  will  not  be  necessary  to  look  which  way  the  ligature  is  twisted 
each  time  it  is  tightened. 

Where  spurs  have  been  placed  on  the  arch  to  prevent  the  ligature 
from  slipping,  the  ligature  should  be  passed  below  the  occlusal  side  of 
the  arch  and  the  end  brought  up  over  the  gingival  portion,  which 
makes  one  turn  around  the  arch,  and  the  end  then  passed  between  the 
teeth  in  the  usual  manner.  This  wrap  (Fig.  218)  around  the  arch  pre- 
vents the  ligature  from  slipping  over  the  spur  should  the  teeth  move 
and  the  ligature  become  very  loose.  The  manner  of  making  spurs  on 
the  arches  will  be  considered  with  arches. 

Fixed  Regulating  Appliances 

The  main  part  of  the  fixed  regulating  appliance  consists  of  some 
form  of  the  screw  or  spring  lever.     The  force  is  the  screw  force  and 


REGULATING  APPLIANCES 


185 


the  force  of  the  spring.    The  two  forces  have  been  combined  in  the  ex- 
pansion arch. 

The  jack-screw,  which  was  the  first  appliance  placed  on  the  mar- 
ket and  constructed  so  that  it  could  be  used  on  different  cases,  has 
been  made  in  many  different  forms.  The  best  jack-screw  consists  of 
three  pieces — screw,  nut  and  tube.  The  object  of  the  tube  is  to  cover 
up  the  free  end  of  the  screw  so  that  it  will  not  (Fig.  219)  annoy  the 


©ad 


Fig.    219. — Angle's   jack-screw. 

tongue,  and  it  also  affords  attachment  for  one  end  of  the  appliance. 
There  are  many  different  av;ivs  of  attaching  the  screw  to  the  teeth  that 
are  to  be  moved.  The  kind  of  anchorage  that  is  used  will  determine 
what  form  of  attachment  is  to  be  made.     The  advantage  of  the  jack- 


f~~\      fp -■  --      |     fl^i^f^^mntT" 


~~©bw» 


Fig.  220. — rAngle's  traction  screw. 

screw  lies  in  the  amount  of  force  that  can  be  exerted,  the  control  of 
the  force,  and  the  firm  manner  in  which  it  can  be  attached  to  the 
teeth.  The  disadvantage  lies  in  the  limited  application  of  the  device. 
The  jack-screw  exerts  force  only  in  one  direction,  and  when  a  number 


e        c 

Fig.  221.- — Lourie's  ligature  jack. 

of  different  tooth  movements  have  to  be  made,  it  becomes  necessary 
to  use  many  combinations  of  jack  screws,  making  the  appliance  very 
complicated  and  bunglesome.  The  traction  screw  is  only  a  modifica- 
tion of  the  jack-screw  and  is  used  for  pulling  (Fig.  220).  It  is  very 
seldom  that  either  of  these  appliances  is  used,  as  the  improvement  of 
the  expansion  arch  and  the  use  of  the  intermaxillary  anchorage  makes 


186 


PRACTICAL    ORTHODONTIA 


it  possible  to  treat  eases  more  easily  with  the  arch  than  with  the  jack- 
screw  and  traction  screw. 

A  very  ingenious  and  useful  form  of  jack  has  been  devised  by  Lou- 
rie, which  is  known  as  the  "ligature  jack."  It  embodies  the  principle 
of  the  traction  cable,  and  the  appliance  is  so  constructed  that  the  force 
of  the  silk  ligature  or  traction  cable  is  exerted  between  two  points.    It 


Fig.    222. — Ligature   jack    used    with    stationary    anchorage.      (Lourie.) 

can  be  used  for  the  expansion  of  the  arch  by  pitting  it  against  teeth 
on  the  opposite  side  of  the  arch  or  fur  moving  a  single  tooth  by  the 
employment  of  stationary  anchorage.  It  consists  of  a  piece  of  heavy 
tubing  (Fig.  221-a)  of  19-gauge  which  has  a  longitudinal  (&)  22- 
gauge  slot  cut  in  it  and  a  piece  of  19-gauge  wire  (c)  to  which  has  been 
soldered  a  spur  of  22-gauge  wire  (d).  A  22-gange  spur  (e)  is  also  sol- 
dered to  the  end  of  the  tubing.    A  piece  of  traction  cable  (/)  is  tied  be- 


Fig.    223. — Ligature   jack    used    to    relieve    impaction    of    third    molar.       (Lourie.) 

tween  the  spurs  d  and  e  and  as  a  result  of  the  contraction  of  the  cable, 
force  is  exerted  on  the  tooth  to  be  moved.  The  construction  of  the  liga- 
ture jack  for  use  with  stationary  anchorage  is  shown  in  Fig.  222.  The 
appliance  can  be  employed  for  elevating  and  straightening  a  molar, 
as  shown  in  Fig.  223.  As  a  reciprocal  appliance  for  the  widening  of 
the  arch  it  can  be  attached  to  the  deciduous  canines,  as  shown  in  Fig. 
224.  This  principle  can  be  used  with  the  alignment  wire  in  length- 
ening the  lateral  halves  of  the  arch  and  can  be  made  curved  to  fit  the 


REGULATING  APPLIANCES  187 

anterior  part  of  the  arch  in  the  incisal  regions.  The  author  is  of  the 
opinion  that  it  is  one  of  the  most  useful  principles  that  has  been  given 
to  us  in  the  construction  of  appliances.  It  requires  very  little  atten- 
tion, and  moves  the  teeth  with  no  pain. 


Fig.  224. — Ligature  jack  employed   to  widen   maxillary  arch.      (Lourie.) 

Alignment  Wires  or  Expansion  Arches 

One  of  the  principal  fixed  regulating  appliances  employed  is  the 
alignment  wire,  which  has  been  called  the  expansion  arch.  For  some 
time  this  type  of  appliance  consisted  of  a  threaded  arch,  as  shown  in 
Fig.  225,  which  was  employed  for  expanding  the  arch — hence  the 
name  expansion  arch.  It  was  found  in  the  treatment  of  malocclusions 
that  it  was  sometimes  necessary  to  contract  the  dental  arch,  and  with 
the  advent  of  intermaxillary  anchorage  that  it  was  desirable  to  move 
the  teeth  forward  and  backward  with  the  expansion  arch,  so  Lischer 
sui^ested  that  the  appliance  be  called  "alignment  wire,"  as  it  was 
more  descriptive  and  less  confusing.  For  instance,  we  might  contract 
the  dental  arch  with  the  expansion  arch,  Avhich  is  a  statement  that  ap- 
pears rather  contradictory ;  however,  if  we  say  that  we  contracted 
the  dental  arch  with  the  alignment  wire,  the  statement  is  not  confus- 
ing. 

Alignment  wires  may  be  classified  into  the  labial  and  the  lingual 
alignment  wires  or  arches.  Of  the  labial  alignment  wires  we  have  the 
threaded  arches  that  are  made  in  one,  two,  or  three  pieces.  The  one- 
piece  alignment  wire,  or  arch,  is  the  most  used.  The  three-piece  arch 
was  recommended  for  use  with  the  pin  attachment  for  bodily  tooth 
movement.     AVe  also  have  the  plain  labial  alignment  wires,  one  type 


188  PRACTICAL    ORTHODONTIA 

of  which  lias  been  called  the  loop  appliance,  because  the  appliance 
possesses  a  number  of  loops  for  the  purpose  of  increasing  the  efficiency 
of  the  expansive  or  contractive  force. 

Lingual  alignment  wires,  or  arches,  are  placed  on  the  lingual  side  of 
the  teeth  and  can  be  divided  into  the  fixed  and  the  removable.  The 
fixed  lingual  alignment  wire  is  soldered  directly  to  the  molar  bands, 
and  the  force  for  moving  the  teeth  is  obtained  by  pinching  and  bend- 
ing the  alignment  wire.  The  removable  lingual  alignment  wires  are 
attached  to  the  anchor  bands  by  some  form  of  a  locking  device  that 
will  permit  the  removal  of  the  alignment  wire  from  the  anchor  bands. 
Lingual  alignment  wires  are  generally  used  without  any  threads, 
although  threaded  lingual  arches  have  been  employed  by  some.  The 
use  of  the  thread  greatly  increases  the  bulk  of  the  appliance,  and  the 


Fig.    225. — Expansion   arch    with    different    forms    of    nuts. 

making  of  the  appliance  more  bulky  defeats  one  of  the  good  qualities 
of  the  lingual  alignment  wire,  which  is  lack  of  bulk. 

The  labial  alignment  wire  or  expansion  arch  (Fig.  225)  has  been 
evolved  from  different  forms  of  appliances  until  at  the  present  time 
it  embodies  several  principles  in  a  single  appliance.  It  is  possible  to  do 
anything  with  the  labial  alignment  wire  that  can  be  done  with  any 
other  appliance,  and  to  do  it  easier  and  quicker  and  with  less  pain  than 
is  possible  with  some  others.  It  is  possible  to  move  a  tooth  in  any  di- 
rection except  that  of  depressing  it  in  the  socket,  which  movement  is 
even  maintained  by  some.  The  expansion  arch,  or  alignment  wire, 
can  be  used  with  any  of  the  three  forms  of  anchorage.  Crude  forms  of 
the  alignment  wire  were  used  by  practitioners  for  a  number  of  years, 
but  it  was  not  employed  as  a  universal  appliance  until  the  writings  of 
Angle  were  given  to  the  profession.     The  present  form  of  the  align- 


REGULATING  APPLIANCES  189 

merit  wire  can  be  traced  to  the  plain  arch  of  Angle,  which  was  a  part 
of  his  device  for  the  treatment  of  prominent  upper  anterior  teeth.  Case 
employed  forms  of  the  alignment  wire  in  the  construction  of  his  con- 
touring appliance.  Ainsworth  likewise  used  another  form  of  the  arch 
in  his  appliance,  which  has  been  known  as  the  "Ainsworth  appliance." 
The  Ainsworth  appliance,  as  originally  made,  was  limited  to  the  ex- 
pansion of  the  teeth  and  not  adopted  to  the  various  tooth  movements 
as  was  the  Angle  arch.  As  stated  before,  the  plain  arch  that  was  used 
in  the  retraction  of  the  upper  anterior  teeth,  may  be  said  to  lie  the 
forerunner  of  the  modern  alignment  wire.  In  the  plain  arch,  we  have 
a  long  spring,  which  is  an  ideal  appliance  for  exerting  force  upon  the 
lateral  halves  of  the  arches  by  means  of  reciprocal  anchorage.  With 
occipital  anchorage,  it  was  possible  to  accomplish  good  results  in  a 
certain  number  of  cases,  namely,  distoclusion  with  protruding  incisors, 
or  Class  II,  Division  1.  However,  these  results  were  not  ideal,  and  in 
the  treatment  of  neutroclusion,  or  Class  I  cases,  with  its  various  types, 
and  distoclusion  with  retruding  anterior  teeth,  or  Class  II,  Division  2, 
and  mesioclusion,  or  Class  III,  cases,  various  combinations  of  appli- 
ances were  used  and  the  results  were  not  always  ideal.  By  threading 
the  ends  of  the  plain  round  arch  and  putting  on  the  nut,  we  have  an 
appliance  that  combines  the  force  of  the  spring  lever  and  the  jack- 
screw.  Then  with  the  improvement  of  intermaxillary  anchorage,  it  be- 
came possible  to  accomplish  better  results  than  had  ever  been  accom- 
plished before.  With  the  proper  adjustment  of  the  arch  and  the  addi- 
tion of  a  few  devices  for  the  movement  of  the  roots  of  the  teeth,  the 
results  that  can  be  accomplished  are  only  limited  by  the  ability  of  the 
operator. 

The  expansion  arch,  or  alignment  wire,  as  designed  by  Angle,  pos- 
sesses a  patented  nut  with  a  friction  sleeve,  as  shown  in  Fig.  225,  which 
slips  in  the  end  of  the  tube  on  the  molar  band.  The  round  end  of  the 
nut  fitting  in  the  tube  prevents  the  cheeks  from  working  the  nut  loose. 
In  order  to  be  of  any  benefit  the  round  end  of  the  nut  must  fit  the  tube 
closely.  Another  feature  of  some  of  the  Angle  arches  is  the  making 
of  a  small  rib  into  which  notches  can  be  filed  (Fig.  226),  which  pre- 
vents the  ligatures  from  slipping  on  the  arch.  Owing  to  the  fact  that 
the  rib  on  the  arch  interferes  with  the  even  spring  of  the  wire  and  in 
a  great  many  cases  greatly  irritates  the  lips,  the  ribbed  arch  is  not 
used  in  the  author's  practice.  The  ribbed  arch  wTas  designed  to  allow 
the  placing  of  a  notch  in  the  rib  for  the  purpose  of  engaging  the  liga- 
ture so  that  it  would  not  slip.  The  rib  greatly  interfered  with  the 
spring  of  the  arch,  and  the  Lourie  spur  forming  plier  was  designed 


100  PRACTICAL    ORTHODONTIA 

for  the  purpose  of  making  a  spur  on  the  arch  without  taking  the  arch 
out  of  the  mouth..  This  form  of  pliers  has  strong  beaks,  which  grasp 
the  alignment  wire  firmly,  while  a  short  lever  that  moves  a  sharp 
chisel  is  pushed  down  on  the  alignment  wire,  cutting  a  small  delicate 
spur  in  the  wire  without  injuring  the  alignment  wire. 

Other  arches  are  made  by  different  manufacturers  and  various  forms 
of  nuts  have  been  designed  in  such  a  manner  that  the  cheeks  will  not 
work  them  loose.  Lock  nuts  are  placed  on  the  arch ;  others  are  made 
with  specially  designed  nuts  to  prevent  them  from  working  loose. 
Some  nuts  are  made  six  and  eight  sided  in  order  that  the  angles  will 
not  be  so  sharp  against  the  cheek.  Various  other  details  to  accom- 
plish certain  results  have  been  added  by  orthodontists  in  the  past,  but 
they  have  always  produced  complications  that,  in  the  author's  opinion, 
have  often  defeated  the  end  sought.  Alignment  wires,  or  expansion 
arches,  are  made  from  various  materials.    Nickel  silver  has  been  more 


Fig.   226. — Angle's   ribbed   expansion   arch. 

widely  used  in  the  making  of  arches  tfyan  any  other  material.  It  is 
capable  of  being  tempered  so  as  to  give  the  necessary  spring.  At- 
tachments to  nickel  silver  arches  must  be  made  with  soft  solder,  for 
the  use  of  silver  or  gold  solder  will  destroy  the  temper.  As  it  is 
antiseptic  nickel  silver  saves  a  great  many  teeth  from  decay,  which 
would  occur  if  gold  or  some  other  noble  metal  were  used.  The  objec- 
tion has  been  made  that  they  discolor.  The  author  much  prefers  an 
appliance  that  demands  care  in  order  to  keep  it  clean  than  one  that 
invites  decay.  Gold  and  platinum  came  into  great  favor  a  few  years 
ago,  recommended  by  its  color  and  by  the  fact  that  it  possessed  more 
spring  than  nickel  silver  and  could  be  used  in  a  smaller  gauge.  Also, 
attachments  can  be  made  to  it  with  hard  solder  without  destroying  the 
temper.  In  a  great  many  mouths  it  discolors  more  than  nickel  silver, 
and  the  great  disadvantage  is  the  absence  of  any  antiseptic  property. 
Iridio-platinum  is  also  used  and  has  the  same  advantages  and  disad- 
vantages that  gold  and  platinum  has.     One  of  the  recent  metals  or  al- 


REGULATING  APPLIANCES 


191 


loys  to  be  used  is  aluminum-bronze,  which  the  author  believes  more 
nearly  approaches  the  ideal.  It  has  all  of  the  advantages  of  nickel 
silver  and  many  of  the  advantages  of  gold  and  platinum,  except  that 
it  cannot  be  soldered  with  hard  solder  without  destroying  the  temper. 
The  color  is  better  in  a  higher  percentage  of  mouths  than  any  other 
metal.  It  can  be  made  very  tough  and  springy,  and  arches  of  small 
gauge  can  be  used. 

Iridio-platinum,  because  of  its  stiffness,  makes  a  very  desirable  ma- 
terial for  the  construction  of  the  fixed  lingual  arch.  It  is  also  tough 
and  works  nicely  with  the  wire-stretching  pliers,  which  are  necessary 
for  the  use  of  the  fixed  lingual  alignment  wire.     An  alloy  of  iridio- 


Fig.    227. — The    Lourie    spur    pliers. 


platinum  containing  about  16  per  cent  of  iridium  is  best  for  use  with 
the  wire-stretching  pliers.     Nineteen-gauge  is  generally  employed. 

Gold  and  platinum,  elastic  gold,  and  high-fusing  clasp  metal  are  em- 
ployed in  the  construction  of  the  removable  lingual  arch  because  they 
are  slightly  more  elastic  than  is  iridio-platinum.  These  are  also  gen- 
erally used  in  19  gauge. 

Sixteen-gauge  is  employed  more  in  the  threaded  labial  arches. 
Arches  of  18  gauge  are  often  used  on  the  deciduous  teeth  and  in  neutro- 
clusion, or  Class  I,  cases  where  only  intramaxillary  anchorage  is 
used.     If  a  smaller  gauge  than  18  of  anv  metal  is  used  there  is  great 


192  PRACTICAL    ORTHODONTIA 

danger  that  the  .small  diameter  of  the  arch  cuts  into  the  cheek.  Arches 
of  very  small  gauge  have  been  introduced  by  Angle  under  the  name 
of  "The  New  Angle  Appliances,"  and  the  ribbon  arch.  Small  gauge 
arches  are  also  used  by  Robinson  in  the  Robinson  appliance.  These 
have  some  advantages  and  some  disadvantages.  However,  they  have 
been  used  successfully.  The  16-gauge  arch  will  long  be  the  standard 
size,  for  it  can  be  universally  used.  It  possesses  the  required  spring 
and  strength,  without  taking  up  too  much  room. 

Attachments  for  the  Alignment  Wire  or  Expansion  Arch. — It  will 
often  be  found  necessary  to  make  three  attachments  to  the  expansion 
arch  for  various  purposes:  first,  a  spur  to  prevent  the  ligature  from 
slipping  on  the  arch  and  to  control  the  direction  in  which  the  force  is 
exerted;  second,  an  intermaxillary  hook  for  use  in  intermaxillary 
anchorage,  and  third,  a  spring  extension,  or  spur,  for  the  movement 
of  the  teeth. 

Spurs  to  prevent  the  ligatures  from  slipping  on  arches  made  of  nickel 
silver  or  aluminum-bronze  must  be  attached  with  soft  solder.  On 
the  gold  and  platinum  and  iridio-platinum  arches  these  spurs  can  be 
attached  with  gold  solder.  The  spurs  can  be  made  out  of  ligature 
wire,  a  tube  or  a  wire  heavier  than  ligature  wire.  There  is  little  need 
that  the  spur  be  higher  than  the  diameter  of  the  ligature  that  it  is  to 
hold  on  the  arch.  The  simple  spur  (Fig.  228-A)  is  made  by  flowing  a 
little  solder  on  the  end  of  the  ligature  wire  and  then  soldering  to  the 
arch.  Soft  solder  requires  the  use  of  a  soft  solder  flux.  A  saturated 
solution  of  zinc  chloride  makes  the  best  that  the  author  has  tried.  This 
simple  spur  is  of  little  practical  value,  for  if  much  force  is  to  be  exerted 
on  the  ligature  it  will  tear  off.  The  half -loop  spur  (Fig.  228-D)  is  made 
by  bending  a  piece  of  the  ligature  wire  so  that  it  will  half  encircle  the 
arch.  Soft  solder  is  flowed  in  the  bend,  the  wire  is  held  in  the  proper 
position  on  the  arch,  heat  is  applied,  and  the  wire  soldered  to  the  arch. 
The  ends  of  the  wire  are  cut  off  leaving  the  spur.  If  this  spur  is  sol- 
dered to  the  noble  metal  arch  with  hard  solder,  it  will  be  strong  enough, 
provided  that  the  spur  has  been  so  placed  that  the  ligature  pulls  from 
the  entire  length  of  the  spur  and  not  against  one  end.  In  those  cases 
where  it  is  necessary  to  open  space  for  an  impacted  tooth,  e.  g.,  a  second 
premolar,  a  strong  spur  is  necessary.  This  is  best  made  by  wrapping  a 
wire  twice  around  the  arch  (Fig.  228-B)  at  the  proper  place  and  flow- 
ing solder  entirely  around  the  arch  (Fig.  228-C).  The  ends  are  then 
trimmed  and  filed  close,  which  makes  a  spur  that  is  neat  and  capable 
of  withstanding  all  the  force  necessary.  This  spur  can  be  made  as  neat 
and  strong  as  a  tube,  and  much  quicker.     In  using  a  tube  for  a  spur, 


REGULATING   APPLIANCES 


193 


a  piece  of  tubing  is  selected  with  an  inside  gauge  the  same  as  the  gauge 
of  the  arch.  A  piece  is  cut  from  the  tube  of  sufficient  length  to  afford 
solder  attachment  that  will  be  strong  enough  to  withstand  the  force, 
the  nut  removed  from  the  arch  and  the  tube  slipped  to  the  desired  posi- 


Fig.    228. — Forms    of    soft-solder    spurs.      A,    simple    spur;    B,    wire-twisted    before    flowing    soft- 
solder;    C,    spur   made    by    flowing   soft-solder    over    B;    D,    half-loop    spur. 

tion  on  the  arch,  which  has  previously  had  flux  placed  on  it.  A  small 
piece  of  solder  is  laid  on  the  arch  at  one  end  of  the  tube.  The  other 
end  of  the  tube  is  then  heated  and  the  solder  "pulled"  through  the 
tube.  Split  tubes  that  can  be  placed  on  the  arch  without  removing  the 
nut  are  obtainable,  but  they  are  not  so  strong. 

The  second  attachment  to  be  placed  on  the  expansion  arch  is  the 


-C>"::: 


[!'.'--- 


::::0- 


..--'.~> 


Fig.  229. — A,  sheath-  or  intermaxillary-hook  made  by  soldering  wire  to  tube  and  soft-solder- 
ing tube  to  arch.  B,  Intermaxillary-hook  made  twisting  ligature  wire  around  arch  to  which  it 
is   then   fastened  with   soft-solder. 

sheath-,  intermaxillary-,  or  tube-hook.  These  different  terms  are  synon- 
ymous, and  the  hooks  consist  of  some  form  of  attachment  for  the  rubber 
ligatures  when  intermaxillary  anchorage  is  used.  Sometimes  hooks  are 
placed  on  the  arches  to  engage  a  rubber  ligature  not  used  "with  inter- 


194  PRACTICAL    ORTHODONTIA 

maxillary  anchorage,  in  which  ease  the  term  intermaxillary-hook  would 
be  wrong.  The  standard  form  of  sheath-hook  consists  of  a  piece  of 
wire  soldered  to  a  small  tube  and  bent  in  the  form  of  a  hook,  as  shown 
in  Fig.  229-A.  The  lube  is  slipped  over  the  arch  and  attached  in  the 
same  manner  that  a  tube  is  soldered  to  the  arch,  as  described  on  page 
193.  Various  forms  of  hooks  have  been  made,  but  one  that  is  simple 
serves  the  purpose  as  well  as  one  of  peculiar  pattern.  Hooks  can  be 
made  by  wrapping  a  wire  around  the  arch  and  bending  the  ends  in  a 
hook,  then  soldering  it  so  as  to  attach  the  ware  to  the  arch,  and  strength- 
ening the  wire  in  the  hook  portion  (Fig.  229-5).  This  hook  is  neat  and 
strong  and  can  be  made  without  taking  the  nut  off  the  arch.  Very  often 
the  hooks  can  be  placed  on  the  arch  so  as  to  serve  the  purpose  of  the  spur 
also.  When  gold  and  platinum  or  iridio-platinum  arches  are  used,  ;i 
piece  of  wire  of  suitable  gauge  can  be  soldered  to  the  arch  direct,  with 
hard  solder,  and  then  bent  into  a  hook. 

The  third  form  of  attachment  to  the  arch  is  spurs  for  the  bodily  move- 


Fig.  230. A,  spur  used   to  depress  prominent  canines;   B,  spur   used   in   bodily  movement  of  teeth. 

mi  nt  of  the  teeth,  or  spurs  to  move  the  apex  mure  than  the  crown,  or  to 
depress  teeth. 

As  these  spurs  must  withstand  considerable  force,  it  is  necessary  that 
they  be  firmly  attached  to  the  arch.  With  gold  and  platinum  and  iridio- 
platinum  arches  the  spur  can  be  soldered  directly  to  the  arch.  The 
spur  should  be  so  placed  that  it  will  occupy  a  central  axis  of  the  tooth 
mesio-distally.  The  tooth  is  attached  to  the  arch  and  held  in  such  a 
manner  that  it  will  occupy  a  perpendicular  relation  to  the  spur.  If  the 
apex  is  to  move  more  than  the  crown,  the  spur  is  so  bent  as  to  exert 
that  manner  of  force.  When  nickel  silver  or  aluminum-bronze  is  used, 
hard  solder  cannot  be  employed  or  the  temper  of  the  arch  will  be  de- 
stroyed. In  that  case  the  wire  is  soldered  to  a  tube  (Fig.  230-A)  that 
is  the  right  size  to  slip  over  the  arch.  The  tube  is  placed  at  the  proper 
position  on  the  arch  and  pinched  slightly  with  a  wire  cutter.  The 
pinching  of  the  tube  with  a  wire  cutter  makes  the  tube  fit  tightly  to  the 
arch  so  that  it  will  not  turn  and  slip  while  the  arch  is  being  removed  from 
the  mouth  and  placed  over  the  flame  to  be  soldered.     The  tube-spur  is 


R I  •:<  1UL  VII  N  i ;  APPLIANCES  1 95 

soldered  by  placing  flux  and  solder  at  one  end  of  the  tube  and  gently 
heating  the  other  end  to  pull  the  solder  through  the  tube  (Fig.  230-B). 

Application  of  the  Labial  Alignment  Wire  or  Expansion  Arch.— As 
the  labial  expansion  arch,  with  the  bands  and  ligatures  that  go  with 
it,  is  the  most  widely  used  of  all  appliances,  it  becomes  necessary  that 
the  principles  of  applying  the  arch  be  fully  understood.  In  the  hands 
of  the  skilled,  or  in  the  hands  of  those  who  properly  adjust  it,  it  be- 
comes a  valuable  appliance — so  valuable  that  it  is  the  only  form  of  ap- 
pliance that  is  needed,  with  the  occasional  use  of  the  traction  screw. 

It  must  be  remembered  that  the  arch  embodies  two  forms  of  mechani- 
cal devices —  the  screw  and  the  spring  lever;  therefore  we  have  an  enor- 
mous amount  of  mechanical  force  at  our  disposal. 


Fig.    231. — Case    in    which    anterior    teeth    only    need    moving. 

In  using  the  expansion  arch,  or  alignment  wire,  one  must  be  familiar 
with  the  various  forms  of  anchorage  in  order  to  obtain  the  best  results. 
In  applying  the  alignment  wire,  or  expansion  arch,  to  move  the  anterior 
teeth  forward,  we  depend  upon  simple  anchorage  obtained  from  the 
molar  teeth  that  have  been  fitted  with  bands.  The  tubes  on  the  molar 
band  must  be  so  placed  and  the  sides  of  the  arch  aligned  so  that  the 
tube  and  arch  will  be  parallel  to  each  other  before  the  arch  is  placed 
in  the  tube.  If  this  is  not  done,  the  molars  will  be  rotated  by  the  spring 
of  the  arch  if  the  arch  is  not  parallel  to  the  tube.  In  moving  the  anterior 
teeth  forward,  if  that  is  the  only  movement  that  is  to  be  made,  as 
seen  in  Fig.  231,  the  sides  of  the  arch  are  only  as  wide  as  the  tubes  on 


19G  PRACTICAL    ORTHODONTIA 

the  molar  band  (Fig.  232).  It  is  unnecessary  to  spring  the  arch  to  get 
it  in  the  tubes.  The  side  of  the  arch  lies  close  to  the  teeth  so  as  to  avoid 
any  irritation  to  the  cheeks.  The  anterior  portion  of  the  arch  stands 
slightly  away  from  the  teeth.  In  applying  the  arch  to  this  class  of 
cases,  one  side  of  the  arch  is  placed  in  the  tube  on  the  molar  band  and 
the  position  noted.  If  the  arch  is  too  long,  the  nut  is  turned  forward 
until  the  arch  is  the  proper  size,  and  if  the  end  projects  through  the 
tube,  the  end  of  the  arch  is  cut  off  so  that  it  will  be  covered  by  the  tube 
and  not  irritate  the  cheek.  The  arch  is  again  placed  in  the  tube  on  the 
same  side  only,  and  if  the  tube  on  the  band  is  properly  placed,  the  side 
of  the  arch  will  lie  close  to  the  teeth.  The  position  of  the  canine  is 
noted,  a  small  scratch  is  made  opposite  it  and  the  arch  is  removed.     A 


Fig.   232. — Showing   relation   of   screws   on  band  close   to   premolars   and    expansion   arch   without 

any  expansion. 

bend  is  made  in  the  arch  opposite  the  canine  in  order  that  the  anterior 
part  will  lay  close  to  the  anterior  teeth.  This  bend  should  be  made  so 
that  it  will  cause  the  anterior  part  of  the  arch  to  occupy  the  proper  posi- 
tion to  the  six  anterior  teeth.  It  may  be  necessary  to  try  the  arch  sev- 
eral times  before  the  anterior  part  occupies  the  place  intended.  With 
the  same  end  of  the  arch  in  the  same  tube  and  holding  the  arch  in  the 
proper  position  to  the  anterior  teeth,  the  position  of  the  opposite  canine 
is  noted  and  marked  on  the  arch.  The  arch  is  removed,  and  the  bend 
made  in  the  canine  region  where  marked  so  that  the  side  of  the  arch 
occupies  the  proper  relation  to  the  tube.  The  side  of  the  arch  that  was 
first  fitted  on  the  teeth  is  again  placed  into  the  tube  and  all  positions  of 


REGULATING  APPLIANCES  197 

the  arch  noted.  The  side  that  was  bent  last  should  not  be  put  into  the 
tube  until  the  nut  has  been  placed  at  the  proper  position,  the  end  cut 
off  at  the  proper  length,  and  the  side  so  bent  that  the  end  of  the  arch 


Fig.    233. — Position    of   arch    to    expand    molar    without    rotating   same. 


Fig.  234. — Left  side  shows  relation  of  tube  and  arch  to  rotate  mesio-buccal  angle  of  molar. 

lies  parallel  to  the  tube,  when  the  anterior  portion  of  the  arch  is  held 
in  position  with  the  fingers.  This  shows  that  there  is  no  spring  in  the 
arch  that  will  be  exerted  upon  the  molars.     After  it  appears  that  the 


198 


PRACTICAL    ORTHODONTIA 


arch  is  properly  aligned,  insert  the  side  that  was  fitted  last  into  the 
tube,  leaving  the  oilier  side  out,  and  notice  what  position  the  arch  occu- 
pies to  the  tube  when  free.  It  should  lie  parallel  and  in  exact  relation 
to  Hie  tube,  which  shows  there  is  no  spring  on  that  side.    Now  both  sides 


Fig.   235. — Arch  adjusted   to   rotate   distal   angle   of  molar   buccally. 


Fig.    236. — Position    of   arch   to    rotate   mesio-buccal   angle    of   molar    lingually. 

of  the  arch  can  he  placed  in  the  tube  and  it  should  go  into  place  with- 
out binding. 

If  the  arch  is  to  be  applied  to  a  case  that  requires  expansion  in  the 
molar  region,  the  same  procedure  is  followed  in  the  fitting  of  the  arch, 


REGULATING   APPLIANCES 


199 


except  that  the  arch  is  left  wider  in  the  canine  region  and  the  sides  of 
the  arch  are  so  bent  that  they  are  parallel  to  the  tubes  bnt  stand  buccal 
to  the  tubes  before  the  ends  are  inserted  into  them.  Fig.  233  shows  how 
the  ends  of  the  arch  must  be  parallel  to  the  tubes.  If  the  arch  and  tube 
are  not  parallel  the  molar  will  be  rotated  by  the  spring  of  the  arch. 
Very  often  this  is  taken  advantage  of  when  the  molars  are  in  torsi-oc- 
clusion, or  torsiversion.  If  the  arch  and  tube  occupy  the  relation  shown 
in  Fig.  234,  the  mesio-buccal  angle  of  the  molar  would  be  moved  buc- 
cally.  If  they  occupy  the  relation  shown  in  Fig.  235,  the  disto-buecal 
angle  would  be  turned  buccally.    If  they  occupy  the  relation  shown  in 


Fig.    237. — Position   of  arch   and    tube  to   rotate   mesial   angle   of   molar   lingually    and   distal    angle 

buccally. 

Fig.  236,  before  the  arch  is  placed  in  the  tube,  the  mesial  portion  of  the 
tooth  would  be  rotated  lingually.  If  the  tube  and  arch  occupy  the  rela- 
tion shown  to  each  other  in  Fig.  237,  when  the  arch  is  placed  in  the  tube, 
the  molar  would  be  rotated  in  the  center.  Other  forms  of  application 
will  be  shown  in  the  treatment  of  cases. 


Loop  Labial  Alignment  Wires 

The  labial  wire  is  used  also  without  threaded  ends  for  various  tooth 
movements  and  has  become  known  as  the  loop  appliance.  Loops  have 
long  been  used  ill  conjunction  with  other  forms  of  forces.  They  were 
employed  by  Ainsworth  many  years  ago  in  what  has  been  known  as  the 
Ainsworth  appliance.  This  appliance  consisted  in  the  use  of  labial 
arches  that  were  attached  to  the  anchor  bands  by  vertical  tubes  for  the 


200 


PRACTICAL    ORTHODONTIA 


purpose  of  expanding  the  arches.  They  were  also  held  in  place  by  vari- 
ous forms  of  locking  devices.  In  some  cases,  loops  were  made  in  the 
labial  arches,  and  in  others,  the  ends  of  the  labial  arches  were  only  bent 
at  right  angles  and  placed  in  the  perpendicular  tubes  on  the  anchor 
bands.    The  use  of  loops  was  also  early  employed  by  Barnes  and  Pullen. 


Fig  238.  Fig.   239. 

Figs.    238   and   239. — Loop   appliance    and    case    on    which    it    was    used. 


Fig.    240. — Loop    used    in    conjunction    with    pins    and    tubes.       (Pullen.) 


Loops  have  been  used  much  more  extensively  within  the  last  few  years, 
and  are  used  with  appliances  that  are  designed  to  move  teeth  bodily, 
and  also  with  the  plain  wire  ligatures.  The  advantage  of  the  loop  appli- 
ance is  the  ease  with  which  it  can  be  constructed,  owing  to  the  fact  that 


REGULATING   APPLIANCES 


201 


no  threads  or  nuts  are  required.  In  the  absence  of  threads  and  nuts,  the 
tissues  also  take  more  kindly  to  the  appliance.  The  loop  also  gives  a 
greater  range  of  elasticity,  and  can  be  made  to  accomplish  practically 
everything  that  can  be  done  with  the  screw ;  however,  it  must  be  remem- 
bered that  the  spring  force  of  the  loop  is  not  so  positive  as  the  screw 
force  but  that  it  acts  over  a  greater  range.  The  loop  can  be  used  in  the 
treatment  of  simple  cases  or  of  those  that  are  more  complicated.  Fig. 
238  shows  a  simple  case  of  malocclusion,  which  was  treated  by  the  use 
of  the  loop  appliance  shown  in  Fig.  239.  Plain  bands  were  placed  on 
the  molars  for  anchorage,  and  perpendicular  tubes  were  soldered  on 
the  buccal  surface  of  the  molar  bands,  as  can  be  seen  by  studying  the 
appliance  shown  in  Fig.  239.  The  end  of  the  labial  wire  was  bent  gin- 
irivallv  to  form  a  lock  similar  to  the  lock  that  has  been  described  by 


Fig.    241.  Fig.   242. 

Figs.  241   and  242. — The  application  of  the   loop  alignment  wire  in  neutroclusion. 


Young,  and  used  by  others.  A  loop  was  made  in  the  labial  wire  about 
the  region  of  the  first  deciduous  molar  for  the  purpose  of  exerting  the 
force  necessary  to  move  the  incisor  forward,  which  was  in  lingual  oc- 
clusion. 

Another  use  of  the  loop  in  a  simple  appliance  is  shown  in  Fig.  2-10, 
which  was  used  not  as  an  expanding  force  but  as  a  contractile  force  for 
the  purpose  of  moving  the  lateral  toward  the  centrals. 

The  loop  appliance  can  be  used  in  more  complicated  cases  and  is  ex- 
tremely valuable  in  cases  requiring  expansion,  as  shown  in  Figs.  241  and 
242.  The  front  view  shows  a  loop  in  the  lower  wire  in  the  region  of  the 
central  incisors,  which  is  for  the  purpose  of  exerting  an  expansive  force 
in  the  anterior  part  of  the  dental  arch.    By  opening  the  loop,  the  canine 


202 


PRACTICAL    ORTHODONTIA 


portions  of  the  wire  will  be  carried  labially  or  rather  buccally.  In  open- 
ing a  loop  of  this  character,  it  must  be  opened  on  both  sides  so  that  the 
labial  wire  may  be  kept  straight.  Owing  to  the  fact  that  more  expan- 
sion is  required  in  the  upper  dental  arch  than  in  the  lower,  a  loop  is 
made  in  the  upper  alignment  wire  in  the  region  of  the  upper  canines. 
By  turning  this  loop  gingivally  and  by  having  il  press  against  the 
canines,  it  can  be  made  to  exert  a  downward  pressure  on  the  prominent 
canines  if  desired.     By  opening  the  superior  en  nine  loops  the  wire  is 


Fig.    243. — Occlusal    view    of   loop    alignment    wire. 


Fig.    244. — Loop    alignment    wire   used    in    combination    with    threaded    section    of    arch    on    lower 
teeth   for  making  space  to  accommodate  the  premolar. 


increased  in  size  and  room  is  made  for  the  placement  of  the  teeth.  In 
Fig.  242  it  will  be  seen  that  the  lower  wire  has  a  loop  turned  gingivally, 
which  is  directly  in  front  of  the  parallel  tube  on  the  molar  band.  This 
loop  serves  the  double  purpose  of  preventing  the  labial  wire  from  slip- 
ping distally  through  the  tube  and  also  of  providing  a  means  of  in- 
creasing the  length  of  the  lateral  halves  of  the  labial  arch.  Care  must 
be  observed  with  these  labial  loops  that  are  turned  gingivally  that  they 
are  so  bent  thai  they  do  not  impinge  upon  the  gum  tissue.     The  upper 


REGULATING  APPLIANCES 


203 


labial  loop  alignment  wire  is  attached  to  the  anchor  tube  by  means  of 
a  perpendicular  tube  soldered  on  the  band.  The  distal  end  of  the  wire 
is  bent  to  form  a  lock.  As  the  labial  wire  rests  at  the  occlusal  part  of 
the  band,  the  appliance  must  be  bent  gingivally  to  give  the  wire  a  posi- 


Figs.    245    and     !46.-     Loop    alignment    wire    showing    use    of    spur   on    maxillarj    lateral    and    combi- 
nation of  loop  appliance   with   threaded  arch. 


Fig.  247. — Loop  used  in  conjunction  with  threaded  arch  and  pins  and  tubes.      (Pullen.) 


tion  suitable  for  the  attachment  of  wire  ligatures.  It  will  also  be  ob- 
served that  a  loop  is  made  in  the  labial  wire  at  the  region  of  the  pre- 
molars, which  serves  the  purpose  of  a  spur  to  prevent  the  tipping  of 


204  PRACTICAL    ORTHODONTIA 

tlie  premolars  that  are  ligated  tight  to  the  perpendiclar  part  of  the 
loop.     The  occlusal  view  of  the  appliance  is  shown  in  Fig.  243. 

The  loop  appliance  can  be  used  in  various  combinations,  and  different 
attachments  can  be  made  for  various  tooth  movements.  Fig.  244  shows 
the  application  of  the  loop  appliance  to  a  case  that  presents  several  com- 
plications of  adjustment.  The  occlusal  view  of  the  lower  model  shows 
that  the  lower  left  premolar  is  impacted  and  deflected  to  the  lingual. 
The  lower  appliance  is  a  combination  of  the  screw  labial  wire  and  the 
loop  labial  wire.  The  screw  is  used  on  the  left  side  for  the  purpose  of 
moving  the  anterior  teeth  forward  to  make  room  for  the  impacted  tooth. 
On  the  right  side  the  loop  is  attached  to  the  molar  band  by  means  of 
a  perpendicular  spur  in  a  perpendicular  tube.  This  attachment  permits 
a  bucco-lingual  hinge  between  the  band  and  appliance,  and  avoids  a 
tendency  of  the  right  molar  to  be  rotated  as  the  anterior  teeth  are  car- 
ried forward  and  over  by  the  screw  on  the  left  side.  The  occlusal  view 
of  the  upper  model  shows  to  what  extent  the  upper  right  canine  is  in 
lingual  occlusion  and  the  apical  movement  that  is  necessary  for  the 
upper  lateral  incisor.  Figs.  245  and  246  show  the  adjustments  of  the 
appliances  with  the  expansion  spur  on  the  upper  labial  arch  to  control 
the  apical  movement  of  the  lateral  incisor. 

The  loop  is  used  also  in  other  combinations  and  with  other  forms  of 
the  screw,  one  type  of  which  is  shown  in  Fig.  247,  after  Pullen.  Further 
descriptions  of  the  various  combinations  will  be  found  under  the  head 
of  bodily  tooth  movements. 

Lingual  Arches,  or  Alignment  Wires 

Lingual  arches,  or  alignment  wires,  are  distinguished  from  labial 
arches  by  the  fact  that  they  are  placed  on  the  inside  of  the  dental  arch 
or  on  the  lingual  side  of  the  teeth.  Who  was  the  first  to  make  use  of 
tlie  lingual  arch  as  a  regulating  appliance  is  not  known  to  the  author. 
Crude  forms  of  lingual  appliances  have  been  offered  by  certain  manu- 
facturers for  some  time.  The  Jackson  crib  appliance,  or  the  Jackson  re- 
movable appliance,  is  a  lingual  appliance  that  possesses  many  virtues 
and  is  described  in  another  chapter.  Lingual  arches  or  wires  were  also 
used  for  some  years  as  retaining  appliances,  but  the  use  of  the  lingual 
arch  as  a  regulating  appliance,  as  described  in  this  chapter,  belongs  to 
Lourie  and  Mershon,  the  technique  of  each  being  slightly  different. 

The  use  of  the  lingual  arch  as  described  by  Lourie  was  evolved  from 
the  lingual  wire  as  used  in  retention  by  various  practitioners  for  a 
number  of  years,  and  was  brought  to  a  highly  efficient  point  because  of 


REGULATING   APPLIANCES  205 

the  many  valuable  features  that  it  possesses.  The  ease  with  which  the 
appliance  moves  teeth,  the  inconspicuousness  of  the  appliance,  along 
with  the  mechanical  principles  involved  also  influenced  Mershon  in  per- 
fecting his  technique. 

Lingual  arches  may  be  divided  into  the  fixed  and  the  removable,  or 
those  that  are  soldered  to  the  anchor  bands  and  those  that  have  some 
form  of  attachment  to  the  anchor  bands  that  permits  of  their  removal. 
Both  types  are  not  to  be  removed  by  the  patient,  and  in  that  sense  are 
fixed.  The  lingual  arch  that  is  soldered  is  the  type  that  has  been  evolved 
by  Lourie,  and  the  one  with  removable  attachments  to  the  anchor  bands 
has  been  used  by  Mershon. 

Lingual  wires  or  arches  may  also  be  used  with  one  end  soldered  to 
one  molar  band  and  the  other  end  may  have  an  attachment  in  a  tube. 
Lingual  arches  made  with  the  one  side  soldered  to  the  band  and  one  side 


Fig.    248. — Lingual    arch    soldered    to    molar    bands.       (Lourie.) 

attached  into  a  parallel  tube  on  the  opposite  molar  band  offer  many 
advantages  in  relation  to  anchorage  and  tooth  movement  in  certain  forms 
of  malocclusions. 

The  lingual  arch  soldered  to  the  anchor  bands  was  developed  from 
the  retaining  wire  and  was  utilized  by  the  employment  of  the  principle 
of  stretching  wire  with  the  wire  stretchers,  as  first  practiced  by  Angle. 
Lingual  arches  that  are  soldered  to  molar  bands  may  be  used  in  three 
ways  or  for  four  purposes.  First,  they  may  be  used  as  a  retaining  ap- 
pliance which  was  the  first  and  original  use  of  the  soldered  lingual  arch. 
In  this  form  the  lingual  wire  is  passive.  The  second  use  was  evolved 
from  this  passive  form  by  making  the  appliance  active  or  to  exert  force 
on  the  teeth  by  means  of  the  wire-stretching  pliers.  The  third  use  of 
the  lingual  arch  or  wire  is  when  the  appliance  is  used  as  a  form  against 
which  the  malposed  teeth  are  molded,  either  by  means  of  ligature  or 


206 


PRACTICAL    ORTHODONT]  \ 


by  means  of  pressure  exerted  on  the  malposed  teeth  from  the  use  of 
the  high  labial  arch  and  finger  springs.  The  fourth  use  of  the  wire  sol- 
dered to  the  lingual  bands  is  to  use  the  lingual  arch  as  a  means  of  sta- 
bilizing the  anchor  teeth.  This  last  use  is  very  important  and  especially 
when  the  force  on  the  malposed  teeth  is  derived  from  a  small  gauge 
spring  wire  or  finger  spring. 

The  soldered  lingual  arch  is  best  used  by  having  plain  bands  on  the 
anchor  teeth,  which  are  selected  according  to  the  requirements  of  the 
case.    Fig.  248  shows  the  plain  bands  upon  the  second  deciduous  molars 


Fig.   249. — Angle   wire-stretching  pliers. 


Fig.   250. — Lourie   wire-stretching  pliers. 

to  which  the  lingual  wire  is  soldered.  The  technique  of  making  this 
appliance  consists  in  making  the  plain  bands,  placing  them  on  the  teeth, 
and  taking  a  good  modeling  compound  impression.  The  bands  are 
placed  in  the  impression,  and  a  model  is  made  that  has  the  bands  in 
position  on  the  anchor  teeth.  The  lingual  wire  is  then  fitted  to  the  model 
and  soldered  in  place  to  the  bands.  The  lingual  arch  is  shaped  to  give 
the  desired  tooth  movement.  In  Fig.  248  expansion  was  required  in  the 
canine  region,  and  the  arch  is  placed  against  the  lateral  halves  of  the 


REGULATING   APPLIANCES 


20' 


dental  arch  and  the  required  force  is  exerted  by  use  of  the  wire  stretch- 
ers. 

The  wire  stretchers,  as  designed  by  Angle,  are  shown  in  Fig.  249,  and 
are  a  heavy  pair  of  pliers  with  short  round  beaks  for  the  purpose  of 
pinching  the  wire  and  thereby  increasing  its  length.  A  pair  of  pliers 
for  the  same  purpose,  but  much  smaller,  as  designed  by  Lourie,  is  shown 
in  Fig.  250. 

In  considering  the  lingual  arch  it  is  well  to  think  of  it  as  being  com- 
posed of  the  incisal  section,  which  is  that  part  extending  from  one  canine 
to  the  other,  and  the  premolar  and  molar  sections,  which  are  the  right 
and  left  parts  that  are  distal  to  the  canines.     By  pinching  the  wire  in 


Fig.    251. — Bogue    plieri 


Fig.   252. — Modified  How  pliers. 


the  incisal  section,  as  shown  adjusted  in  Fig.  248,  the  canines  will  be 
expanded  and  the  premolar  or  molar  section  will  be  carried  buccally. 
The  expansion  of  the  molars  can  be  increased  by  bending  the  wire 
buccally  distal  to  the  canine  bends,  by  means  of  the  Bogue  pliers  as 
shown  in  Fig.  251.  AVhen  bending  the  premolar  section  of  the  lingual 
arch  buccally  in  the  premolar  region,  there  will  be  a  rotation  of  the 
distal  corner  of  the  molar  buccally  unless  another  slight  bend  or  offset 
is  made  lingually  to  counteract  that  tendency.  The  occlusal  relation  of 
the  soldered  lingual  arch  can  also  be  changed  by  the  use  of  the  modified 
How  pliers,  shown  in  Fig.  252. 

The  lingual  arch  can  also  be  bent  with  the  stretching  pliers  at  the 


208  PRACTICAL    ORTHODONTIA 

time  the  pinch  is  being  made.  This  makes  what  may  be  termed  a  "dead" 
bend,  as  pinching  the  wire  at  the  time  it  is  bent  prevents  the  occurrence 
of  any  backward  spring,  as  is  often  the  case  when  bends  are  made  with 
the  pliers  as  shown  in  Figs.  251  and  252. 

Technique  of  Wire  Stretching1. — In  considering  the  use  of  the  soldered 
lingual  arch  or  wire  it  is  well  to  remember  some  of  the  basic  principles 
employed  in  the  use  of  such  an  appliance.  We  have  already  mentioned 
the  styles  of  wire-stretching  pliers  but  there  is  a  mechanical  principle 
in  the  construction  and  use  of  these  pliers  that  must  be  remembered. 
The  beaks  of  the  pliers  must  be  cylinders  of  the  same  circumference, 
that  are  parallel  at  the  finish  of  the  pinch.  Any  deviation  from  that 
style,  shape  or  relation  of  the  beaks  will  distort  the  wire  and  produce 
a  change  in  the  shape  of  the  appliance  which  will  be  undesirable  and 
produce  pressure  on  the  malposed  tooth  or  anchor  tooth  in  such  a  man- 
ner as  to  defeat  the  purpose  of  the  appliance.  It  must  further  be  re- 
membered that  a  pair  of  wire-stretching  pliers  which  have  the  beaks 
shaped  and  set  to  pinch  one  gauge  of  wire  must  only  be  used  on  that 
gauge.  For  example,  if  beaks  of  the  pliers  are  shaped  and  set  to  pinch 
a  19-gauge  wire  and  they  are  used  on  an  18-gauge  wire,  it  will  be  found 
that  instead  of  the  wire  being  lengthened  in  a  straight  line  or  without 
curvature,  the  ends  of  the  wire  will  bend  away  from  the  pliers.  If  wire- 
stretching  pliers  designed  to  pinch  19-gauge  wire  are  used  on  a  20- 
gauge  wire,  the  ends  of  the  wire  will  be  bent  toward  the  plier  handle. 

Fig.  253  shows  the  relation  the  beaks  of  the  pliers  must  bear  to  each 
other  at  the  close  of  the  pinch.  If  the  beaks  are  parallel  cylinders  (or 
cylinders  of  the  same  diameter  which  are  parallel  to  each  other)  at  the 
close  of  the  pinch,  the  wire  will  be  lengthened  without  any  curvature.  If 
the  external  portion  of  the  beaks  of  the  pliers  close  more  nearly  together 
than  the  internal  portion,  the  ends  of  the  wire  will  be  turned  toward  the 
handle  as  shown  in  Fig.  254.  In  Fig.  254,  A  represents  a  piece  of 
straight  wire  before  the  beginning  of  the  pinch  with  pliers  the  beaks 
of  which  resemble  the  general  outline  shown  in  Fig.  254.  At  the  com- 
pletion of  the  pinch,  the  straight  piece  of  wire  shown  at  A  will  as- 
sume the  position  represented  by  B.  It  can  readily  be  seen  what  a 
large  amount  of  harm  would  be  done  to  a  regulating  appliance  if  a  wire 
was  pinched  with  this  style  of  pliers  without  the  operator  realizing  what 
was  taking  place. 

If,  on  the  other  hand,  pliers  are  used  of  which  the  external  portion 
of  the  beak  does  not  close  as  tightly  ,as  the  internal  portion,  the  wire 
would  be  turned  away  from  the  pliers  as  illustrated  in  Fig.  255. 

A  of  Fig.  255  represents  the  straight  piece  of  wire  before  the  begin- 


REGULATING   APPLIANCES 


>09 


ning  of  the  pinch,  while  B  shows  the  manner  in  which  the  wire  would 
be  curved  if  pinched  by  a  pliers,  the  beaks  of  which  had  a  general  rela- 
tion as  shown  in  Fig.  255.  It  must  be  remembered  that  the  relation 
of  the  beaks  of  the  pliers  as  illustrated  in  Figs.  254  and  255  are  exag- 
gerated, and,  of  course,  can  readily  be  detected  by  the  eye.  In  actual 
practice,  it  must  be  remembered,  that  such  a  small  variation  as  cannot 
be  detected  by  the  eye,  will  produce  changes  in  the  wire  as  illustrated 
in  Figs.  251  and  255.  It  therefore  becomes  necessary  before  using  a  wire- 
stretching  pliers  to  take  a  straight  piece  of  wire  and  pinch  it  outside 
of  the  mouth  and  carefully  observe  what  results  have  taken  place. 

There  is  probably  no  force  used  in  the  correction  of  irregularities 
that  has  as  many  advantages  as  the  force  obtained  from  the  wire-stretch- 
ing pliers  properly  applied.  It  can  equally  be  said  that  there  is  no  force 
which  is  liable  to  do  more  harm  than  that  obtained  from  the  wire-stretch- 
ing pliers,  if  their  use  is  not  understood  or  if  the  beaks  of  the  pliers  are 


i 


Fig.    254. 


Fig.    255. 


improperly  shaped,  because  of  the  fact  the  force  is  exerted  so  gradually 
that  the  tooth  change  occurs  without  the  operator  realizing  how 
these  changes  are  occurring.  We  are  aware  of  the  fact  that  a  great  many 
men  have  begun  using  the  wire-stretching  pliers  before  they  have  be- 
come familiar  with  their  mechanical  action,  and  consequently  have  pro- 
duced many  undesirable  tooth  movements  without  being  aware  of  how 
those  movements  occurred.  The  author  would  caution  all  to  first  be  ab- 
solutely certain  that  the  beaks  of  the  wire-stretching  pliers  are  so  shaped 
as  to  produce  a  straight  pinch,  or  rather  a  pinch  which  will  lengthen 
the  wire  without  bending  it.  Second,  it  must  be  remembered  that  the 
wire-stretching  pliers  adjusted  to  one  gauge  of  wire  cannot  be  used 
on  another  gauge  of  wire.  Third,  it  must  be  remembered  that  the  wire 
used  with  the  wire-stretching  pliers  must  be  one  which  is  capable  of 
giving  an  even  pinch  without  the  wire  becoming  brittle  during  the 
pinching. 


210 


PRACTICAL    ORTHODONTIA 


It  has  been  found  that  some  of  the  alloys  containing  gold  and  platinum 
are  unsuited  for  use  with  the  wire-stretching  pliers  because  these  metals 
seem  to  crystallize  during  the  pinch,  which  results  in  the  wire  breaking 
at  the  place  where  the  pinch  is  made.  Other  alloys  are  entirely  too 
hard  which  have  resulted  in  the  breaking  of  the  wire-stretching  pliers 
;is  well  as  in  producing  a  pinch  that  is  brittle.  At  the  present  time  the 
most  satisfactory  wire  for  use  with  the  wire-stretching  pliers  is  a  16 
per  cent  iridio-platinum  wire.  It  must  also  be  remembered  that  in  mak- 
ing a  pinch  on  a  lingual  or  labial  arch  with  the  wire-stretching  pliers 
a  certain  tooth  movement  will  be  produced  according  to  the  place  and 
manner  in  which  the  pinch  is  made. 

The  following  diagrams  have  been  made  to  show  the  mechanics  of 
the  wire-stretching  pliers,  and  the  changes  that  occur  as  a  result  of  the 
pinch  and  various  manipulations  of  the  pliers  during  the  pinch.  The 
force  resulting  from  the  use  of  the  pliers  is  accurately  shown  in  the 


Af 


Fig.    256. 


Fig.   257. 


Fig.   258. 


diagrams,  and  can  be  proved  by  technical  demonstration,  provided  both 
(in Is  of  the  wire  are  held  rigid  during  the  pinch.  In  the  use  of  the 
wire-stretching  pliers  on  an  appliance,  it  must  be  remembered  that  the 
resulting  movements  of  the  teeth  will  depend  upon  the  anchorage  and  re- 
sistance offered  by  the  supporting  structures. 

The  solid  line  drawing  in  Fig.  256  represents  a  lingual  wire  which 
is  soldered  to  the  molar  band.  If  it  is  desired  to  produce  a  buccal  ex- 
pansion of  the  molar  and  premolar  region,  a  pinch  made  in  the  lingual 
wire  somewhere  in  the  incisal  portion  about  the  region  of  A  will  pro- 
duce a  lengthening  of  the  lingual  wire  from  C  to  C  which  in  turn  will 
carry  the  lateral  halves  of  the  wire  from  C  to  M  buccally.  This  pinch 
made  in  the  incisal  portion  of  the  arch  preferably  near  the  central  part 
will  lengthen  the  wire  from  C  to  C  and  produce  the  expansion  as  shown 
by  the  dash  line  in  Fig.  256.    If  pinches  are  made  in  the  canine  portion 


REGULATING   APPLIANCES  211 

of  the  wire,  a  pinch  must  be  made  on  both  the  right  and  left  side  to 
produce  an  equal  expansion.  If  a  pinch  is  made  only  on  one  side  of  the 
wire  in  the  canine  region,  it  will  produce  a  change  in  the  wire  as  shown 
in  Fig.  262.  In  order  to  produce  an  equal  expansion  in  both  the  canine 
and  molar  regions,  the  pinch  in  the  incisal  portion  at  A  must  be  made 
with  the  beaks  of  the  pliers  held  absolutely  stationary,  without  a  move- 
ment forward  or  backward  or  without  any  rotation  of  the  handle  of  the 
pliers.  It  is  never  advisable  to  make  more  than  two  pinches  at  one  sitting 
in  the  incisal  portion  of  the  arch.  ( 'arc  must  be  taken  not  to  place  enough 
stress  upon  the  wire  between  C  and  C  as  to  produce  a  bend  in  the  wire. 
It  must  remain  absolutely  the  same  except  in  length  in  order  to  pro- 
duce an  expansion  in  the  molar  region  without  rotating  or  tipping  the 
molars.  If  a  sufficient  number  of  pinches  are  made  at  one  sitting  to 
strain  the  wire  and  produce  a  bend  from  C  to  C,  the  molars  will  be 
tipped  or  rotated  in  some  manner. 

In  Fig.  256  it  lias  been  shown  that  if  the  wire-stretching  pliers  are 
placed  in  the  incisal  portion  of  the  alignment  wire  between  C  and  C  and 
a  pinch  is  made  without  moving  the  beaks  the  alignment  wire  will  be 
widened  in  such  a  manner  as  illustrated  by  the  dotted  line. 

•  If  the  alignment  wire  is  pinehed  anywhere  in  the  molar  region  be- 
tween B  and  C  as  illustrated  in  Fig.  257  the  premolar  section  of  the 
alignment  wire  will  be  lengthened  between  B  and  C  and  the  incisal 
section  will  be  carried  forward  to  the  position  represented  by  D;  that 
is,  the  incisal  section  will  be  carried  forward  provided  the  molars  are 
not  moved  distally.  The  purpose  of  Fig.  257  is  to  illustrate  the  possi- 
bility of  lengthening  the  premolar  section  of  the  lateral  halves  of  the 
dental  arch  by  pinching  the  alignment  wire  in  the  premolar  region  and 
carrying  the  incisors  forward  without  any  expansion  in  the  incisal  por- 
tion. 

If  it  is  desired  to  expand  in  the  molar  and  premolar  region,  and  at 
the  same  time  carry  the  incisal  portion  of  the  alignment  wire  forward, 
thereby  expanding  the  dental  arch  in  all  regions,  that  tooth  movement 
can  be  produced  by  making  pinches  in  both  the  incisal  and  the  premolar 
sections  at  points  illustrated  by  A  in  Fig.  258.  In  order  to  produce  this 
increase  in  size  of  the  alignment  wire  and  thereby  expand  the  dental 
arch  as  illustrated  by  the  dotted  line  in  Fig.  258,  the  wire-stretching 
pliers  placed  at  point  A  must  be  held  stationary  and  not  rotated  or  the 
handles  moved  during  the  time  the  pinch  is  being  made.  By  making 
a  pinch  anywhere  between  B  and  C  the  lateral  half  of  the  alignment 
wire  w7ill  be  lengthened,  by  making  a  similar  pinch  between  C  and  C 


212 


PRACTICAL    OiriMIODON'Ti  \ 


the  dental  arch  will  be  expanded  or  the  alignment  wire  will  be  lengthened 
in  the  incisal  portion. 

Kealizing  the  fact  that  any  change  in  shape  of  the  lingual  wire  from 
C  to  C  will  produce  a  certain  degree  of  movement  in  the  molar  region, 
we  will  find  in  certain  cases  it  is  desirable  to  move  the  molars  or  expand 
the  molars  more  than  the  canines.  As  a  result  of  this,  it  is  therefore 
necessary  that  we  be  familiar  with  the  peculiarities  of  the  action  of  wire 
under  the  wire-stretching  pliers  in  order  to  produce  the  movement  de- 
sired in  the  molar  region.  In  Fig.  259  the  heavy  black  line  represents 
the  lingual  wire  soldered  to  the  molar  bands.  In  this  particular  case 
it  is  desired  to  produce  more  of  an  expansion  in  the  molar  region  than 
in  the  canine  region,  and  also  to  produce  an  equal  expansion  of  the  mo- 
lars on  the  right  and  the  left  side.  This  can  be  accomplished  by  plac- 
ing the  wire-stretching  pliers  at  a  point  on  the  lingual  wire  represented 


o. 


■a 


c 


I       c 


Fig.   260. 

by  1A  and  while  the  pinch  is  being  made,  traction  is  made  upon  the 
wire-stretching  pliers  towards  the  molars  so  as  to  change  the  position 
of  the  pliers  from  1A  to  2A.  As  a  result,  the  position  of  the  lingual 
wire  will  be  changed  as  shown  by  the  dotted  line  from  C  to  C  resulting 
in  a  pressure  being  placed  on  the  molars  represented  by  the  dash  line 
from  B  to  C.  This  will  throw  the  right  and  left  molar  region  buccally 
in  the  relation  as  shown  by  the  dotted  line  which  of  course  will  move  the 
distal  portion  of  the  molar  more  buccally  than  the  mesial  portion. 

In  some  instances  it  is  desirable  to  have  this  type  of  expansion  of  the 
molars;  but  instead  of  having  the  distal  end  of  the  molar  moved  more 
buccally  than  the  mesial  end,  it  is  desired  to  move  the  mesial  end  equally 
as  far  as  the  distal.  This  movement  of  the  molar  buccally  in  a  straight 
line  is  then  produced  by  making  a  second  pinch  in  the  lingual  arch  in 


REGULATING   APPLIANCES  213 

the  region  of  the  molar  as  shown  in  Fig.  260.  In  Fig.  260  the  heavy 
black  line  represents  the  lingual  wire  as  shown  by  the  dash  line  in 
Fig.  259.  It  will  be  noted  that  the  distal  end  of  the  heavy  left  back 
arch  is  thrown  out  the  same  as  the  alignment  wire  is  in  Fig.  259.  There- 
fore, if  it  is  desired  to  move  the  molars  buccally  without  any  torsiver- 
sion of  the  distal  corner,  the  wire-stretching  pliers  is  placed  on  the 
arch  at  A  in  the  position  as  shown  by  drawing  1.  As  a  pinch  is  made, 
the  handles  of  the  pliers  are  rotated  distally  from  position  1  to  position 
2  as  shown  by  the  solid  and  dotted  handles.  As  a  result  of  this  move- 
ment a  bend  at  point  A  is  made  in  the  alignment  wire  from  A  to  B  which 
has  no  elasticity.  From  A  to  C  the  alignment  wire  is  sprung,  and  be- 
cause of  this  elactic  spring  from  A  to  C  the  lingual  wire  returns  to  the 
original  position  represented  by  the  black  line  with  the  result  that  the 
dead  bend  from  A  to  B  stays  in  the  alignment  wire,  effecting  a  change 
in  the  position  from  A  to  B  as  represented  by  the  dotted  line.  Because 
of  this  dead  bend  in  the  alignment  wire  in  the  molar  region  the  mesial 
corner  of  the  molar  will  be  rotated  and  made  to  occupy  the  position 
represented  by  the  small  dotted  line. 

By  a  careful  study  of  Figs.  259  and  260  it  will  be  seen  what  a  change 
can  be  produced  in  the  shape  of  the  alignment  wire  by  making  the  two 
pinches  illustrated.  The  first  pinch  made  in  the  incisal  portion  of  the 
wire  (Fig.  259)  at  point  A  and  by  moving  the  pliers  distally  at  the  same 
time  the  pinch  is  being  made  results  in  a  change  shown  by  the  dash 
line  in  Fig.  259.  After  that  pinch  is  made,  the  second  pinch  and  bend 
shown  in  Fig.  260  made  near  the  molar  band  results  in  the  rotation 
of  the  molar.  The  various  changes  shown  in  the  molars  in  these  two 
diagrams  must  be  carefully  carried  in  mind  and  they  also  illustrate 
the  necessity  of  being  perfectly  familiar  with  each  pinch  and  bend  that 
the  wire-stretching  pliers  will  produce  upon  the  various  teeth. 

In  Fig.  261  we  have  an  illustration  that  shows  the  possibility  of  pro- 
ducing a  lingual  movement  in  the  molars  as  a  result  of  the  wire-stretch- 
ing pliers.  Again,  the  heavy  black  line  represents  the  shape  of  the 
alignment  wire  before  any  stress  is  brought  to  bear  upon  it  by  means  of 
wire-stretching  pliers.  In  this  illustration,  the  wire-stretching  pliers 
are  placed  in  position  shown  by  \A  which  is  an  incisal  portion  of  the 
wire  somewhere  between  the  canines  C  and  as  the  pinch  is  made  the 
pliers  is  forced  forward  with  the  result  that  the  incisal  section  of  the 
alignment  wire  is  changed  as  represented  by  the  dash  line.  The  distal 
ends  of  the  alignment  wire,  which  are  soldered  to  the  molar  bands,  will 
be  carried  lingually,  resulting  in  a  narrowing  of  the  molar  region.  There 
are  very  few  cases  in  which  a  lingual  movement  of  the  molars  is  desired ; 


214 


TRACTICAL    ORTHODONTIA 


but  in  those  cases  where  it  is  desired,  it  is  one  of  the  most  satisfac- 
tory means  of  accomplishing  the  change.  The  lingual  movement  of  the 
molars  lias  been  accomplished  in  a  great  man}'  cases  when  men  have 
not  desired  that  movement,  because  they  unconsciously  have  produced 
movement  with  the  wire-stretching  pliers  which  is  illustrated  in  Fig. 
261  in  position  1.1  and  2A  of  the  pliers. 

It  must  be  remembered  that  pinches  made  with  the  wire-stretching 
pliers  at  different  positions  will  produce  different  changes  in  the  shape 
of  the  alignment  wire  and  therefore  produce  different  tooth  movements. 
It  must  also  be  remembered  that  a  radical  different  change  in  the  shape 
of  the  alignment  wire  will  be  produced  when  the  pinch  is  made  in  a 
straight  portion  of  the  wire  or  when  it  is  made  in  a  curved  portion. 
A  large  majority  of  the  lingual  wires  have  a  greater  curve  in  the  ca- 
nine region  as  is  illustrated  in  the  curvature  between  Bl  and  Cl  in 


i\ 


Ci 


0 


G 


o' 


u 


£' 


8'  & 


C*J 


..Ox 


eA 


Fig,  262. 


Fig.  262.  If  the  wire-stretching  pliers  represented  by  A  pinch  the  wire 
in  the  curved  section  between  Bl  and  Cl,  it  will  result  in  a  two-fold 
movement  which  wdll  be  a  carrying  buccally  of  the  premolar  section  to 
the  dash  line  as  shown  between  B2  and  D2.  The  portion  of  the  align- 
ment wire  Cl  will  be  carried  forward  in  the  position  shown  at  C2. 
This  is  the  result  of  the  lengthening  produced  by  the  pinch  made  at  A 
in  the  curved  portion  of  the  alignment  wire  between  B  and  C.  It  will 
be  noticed  that  the  incisal  section  of  the  alignment  wire  as  represented 
by  C  and  E  have  not  been  lengthened ;  neither  has  the  premolar  por- 
tion of  the  alignment  wire  represented  by  that  portion  between  B  and  D. 
The  only  lengthening  in  the  alignment  wire  has  occurred  in  the  curved 
section  between  B  and  C  as  a  result  of  the  pinch  A. 

Pinching  the  alignment  wire  between  the  points  B  and  C,  will  exert 
a  backward  force  upon  the  left  molar  that  will  tend  to  force  it  distally, 
as  illustrated  by  the  dash  line  as  related  to  the  solid  line.     A  forward 


REGULATING  APPLIANCES 


215 


force  will  be  exerted  on  the  right  molar  which  will  tend  to  move  it  for- 
ward. This  force  can  be  utilized  when  it  is  desired  to  move  one  side 
of  the  arch  forward  and  the  other  side  backward,  always  remembering 
that  the  movements  will  vary  according  to  the  resistance  offered  by  the 
various  teeth. 

Several  pinches  can  be  made  in  that  section  of  the  alignment  wire 
between  B  and  C  but  each  pinch,  provided  the  wire-stretching  pliers 
are  held  stationary  and  the  pinch  is  made  at  right  angles  to  the  wire, 
will  result  in  changes  as  shown  by  the  dash  line  and  the  only  lengthen- 
ing wiU  occur  in  that  portion  of  the  wire  between  B  and  C.  If  a  pinch 
is  made  only  in  the  curved  portion  of  the  alignment  wire  on  one  side 
as  illustrated  in  Fig.  262,  it  will  produce  a  change  in  the  shape  of  the 
alignment  wire  as  shown  in  the  dash  line.  In  other  words,  it  will  pro- 
duce an  expansion  in  the  canine  region  of  the  dental  arch  on  one  side 
only  resulting  in  what  might  he  termed  a  warping  of  the  dental  arch 


o 


8 


Xcr^9 


Fig.  263. 


Fig.  264. 


which  can  be  seen  by  studying  Fig.  262.  In  a  number  of  cases  this 
style  of  tooth  movement  may  he  desired,  but  in  other  cases  the  operator 
may  get  this  movement  without  knowing  how  he  produces  it  and  it  may 
not  be  a  desired  movement.  We  therefore  caution  all  who  begin  the 
use  of  the  wire-stretching  pliers  to  realize  that  the  force  produced  is 
constant  and  every  time  a  wire  is  pinched  a  particular  and  positive  effect 
is  produced  according  to  the  position  in  which  the  pinch  is  made,  the 
manner  in  which  the  beaks  are  held  or  moved  during  that  pinch,  and  the 
position  in  which  the  pliers  are  placed  on  the  wire.  Now  this  warping 
of  the  alignment  wire  as  a  result  of  the  pinch  in  the  curved  section  as 
shown  in  Fig.  262  may  he  desirable,  in  fact,  it  can  be  utilized  to  cause 
the  alignment  wire  and  dental  arch  to  assume  a  shape  which  will  result 
in  moving  the  molar  section  forward  on  one  side  and  distal  on  the  other 
as  before  mentioned. 


216  PRACTICAL    ORTHODONTIA 

Fig.  263  shows  the  change  in  shape,  which  would  occur  if  the  align- 
ment wire  was  pinched  an  equal  amount  in  the  canine  region  on  the 
right  and  the  left  side.  Pinches  made  in  the  wire  between  the  points  B 
and  C  would  increase  the  length  of  the  wire  in  that  section  and  leave  the 
length  from  B  to  D  unchanged.  Likewise  the  incisal  portion  of  the  wire 
E  would  be  unchanged. 

In  Fig.  264  we  have  a  diagram  which  requires  a  very  careful  study 
in  order  to  realize  the  peculiar  possibilities  and  movements  which  can 
be  accomplished  by  the  wire-stretching  pliers  used  under  certain  con- 
ditions. Fig.  264,  illustrates  the  possibilities  of  changing  the  shape  of 
the  lingual  alignment  wire  by  means  of  the  wire-stretching  pliers  in 
such  a  manner  as  to  move  one  lateral  half  of  the  arch  forward  and  the 
other  backward  with  no  other  force  except  the  pinched  wire.  The  heavy 
black  diagram  represents  the  shape  of  the  alignment  wire  before  any 
pinches  are  made.  On  the  right  side  of  the  alignment  wire  marked  R 
the  wire-stretching  pliers  are  placed  in  the  canine  region  at  the  point 
on  the  heavy  line  shown  as  1.  As  the  pinch  is  made  the  pliers  is  moved 
distally  to  the  point  shown  at  2  which  results  in  a  change  of  the  curva- 
ture of  the  alignment  wire  in  that  region  represented  by  the  dotted 
line.  On  the  left  hand  side  in  the  canine  region,  the  pliers  represented 
at  1  is  placed  on  the  wire  and  as  the  pinch  is  made  the  pliers  is  forced 
forward,  causing  a  change  in  the  curvature  of  the  wire  as  again  repre- 
sented by  the  dotted  line.  This  results  in  the  canine  portion  of  the  lin- 
gual wire  on  the  right  side  being  so  curved  and  shaped  as  to  assume 
a  distal  spring,  and  the  one  on  the  left  side  is  made  to  assume  a  mesial 
spring.  As  a  result  of  this,  the  right  premolar  region  of  the  alignment 
wire  shifts  distally  from  the  position  3  to  4.  On  the  left  side  a  mesial 
shifting  occurs  in  the  premolar  region  from  the  position  3  to  4.  It  will 
be  seen  then  by  this  diagram,  as  a  result  of  the  pinches  as  outlined,  that 
the  right  half  of  the  alignment  wire  has  shifted  backward  and  the  left 
half  has  shifted  forward.  This  movement  is  very  desirable  in  certain 
cases  and  also  may  be  produced  accidentally  if  the  operator  is  not  fa- 
miliar with  the  technique  of  the  pliers. 

In  some  cases  we  find  it  is  desirable  to  place  upon  the  canines  bands 
to  which  a  wire  has  been  soldered.  Very  often  with  this  style  of  appli- 
ance, it  is  desired  to  change  the  perpendicular  relation  of  the  canines, 
which  can  be  very  easily  accomplished  as  shown  in  Fig.  265.  The  dark, 
heavy  perpendicular  line  and  the  cross  line  represent  the  position  of  the 
canine  and  the  position  which  the  wire  occupies  before  any  pinch  has 
been  made  in  it.  Now,  if  the  wire-stretching  pliers  is  placed  at  A  in 
the  position  1  and  as  the  pinch  is  made  the  pliers  is  moved  occlusally, 


REGULATING    APPLIANCES 


217 


it  will  result  in  a  change  in  the  wire  which  will  produce  a  tipping  of 
the  apices  toward  each  other  and  the  moving  of  the  crown  buccally.  A 
reverse  movement  of  the  canines  can  be  accomplished  as  shown  in  Fig. 
266  if  the  wire-stretching  pliers  A  is  placed  at  the  position  1  and  as 
the  pinch  is  made  is  moved  gingivally  to  2  which  will  change  the  wire 
in  such  a  manner  as  to  tip  the  crown  lingually  and  the  apices  labially 
as  shoAvn  by  the  dash  line.    Besides  being  possible  to  tip  the  canines  in 


/? 


*w 


Fig.  265. 


a 


Fig.  266. 


either  direction  as  shown  by  Figs.  265  and  266  the  expansion  of  the 
canine  can  also  be  accomplished  by  making  straight  pinches  anywhere 
on  the  wire  between  the  two  canines. 

Another  valuable  force  that  can  be  obtained  from  the  use  of  the  wire- 
si  retching  pliers  is  found  in  the  torsional  spring  of  the  wire.  This  force 
is  obtained  by  pinching  and  twisting  the  wire  in  such  a  manner  as  to 
produce  a  torsional  spring  and  a  dead  bend  in  the  wire.  The  nature 
of  the  torsional  spring  and  the  movement  produced  by  it  can  be  best 


Fig.  267. 


Fig.   26 


Fig.   269. 

understood  by  studying  Fig.  267  which  represents  a  straight  piece  of 
wire  without  any  torsional  spring.  The  wire  is  attached  at  the  ends  A 
and  B.  The  pliers  is  placed  at  the  point  C  and  as  the  wire  is  gripped 
between  the  beaks,  the  pliers  is  rotated  so  as  to  twist  the  wire  as  shown 
in  Fig.  268.  From  the  point  A  to  C  in  Fig.  268  the  wTire  is  twisted  be- 
yond the  range  of  elasticity  and  remains  in  that  shape.  From  C  to  B 
the  wire  has  a  torsional  spring  and  returns  to  its  original  shape  as  shown 


218 


PRACTICAL    ORTHODONTIA 


in  Fig.  269.  In  Fig.  269  the  end  of  the  wire  A  will  be  rotated  by  the 
torsional  spring  in  that  portion  of  the  wire  from  C  to  B  provided  the 
end  B  is  attached  to  a  point  sufficiently  rigid  to  overcome  the  force.  The 
use  of  the  torsional  spring  in  the  wire  is  shown  in  Fig.  270. 

If  we  have  bands  upon  the  canines  to  which  a  wire  lias  been  soldered, 
we  can  tip  one  canine  mesially  or  dist ally  or  in  some  instances,  one 
mesially  and  the  other  distally.  This  movement  is  accomplished  by  put- 
ting a  torsional  spring  in  the  wire  as  illustrated  in  Fig.  270.  The  heavy 
shaded  lines,  perpendicular  and  cross  lines,  represent  the  position  of 
the  canines  which  have  been  banded  and  connected  by  a  labial  wire. 
If  it  is  desired  to  tip  the  right  canine  forward  as  represented  by  B 
and  have  a  distal  movement  of  the  apex  of  the  tooth,  the  wire-stretching 
pliers  A  is  placed  on  the  wire  in  the  position  shown  at  1.  As  the  pinch 
is  made,  the  handles  of  the  pliers  are  rotated  occlusally,  effecting  a 
torsional  bend  in  the  wire  represented  by  the  arrow  between  1  and  2. 
Between  the  points  A  and  B  a  dead  bend  is  made  in  the  wire  owing  to 


8 


C-. 


Fig.   270. 


Fig.  271. 


the  short  distance  between  the  pinch  and  the  soldered  attachment.  Be- 
tween A  and  C  a  torsional  spring  is  made  which  being  a  live  spring 
causes  that  portion  of  the  wire  to  return  to  its  original  shape,  and  the 
canine  B  is  moved  to  the  position  represented  by  the  dash  line.  There  is 
an  equal  force  exerted  on  the  canine  C  which  would  have  a  tendency 
to  tip  that  tooth  in  the  position  shown  by  the  dash  line. 

In  studying  Fig.  270,  it  must  be  borne  in  mind  that  this  movement 
occurs  because  of  the  fact  that  in  rotating  the  pliers  A  from  1  to  2  a 
dead  bend  is  made  between  A  and  B,  while  between  A  and  C  we  have 
an  active  spring,  or  an  active  bend,  which  contains  a  spring  force,  that 
results  in  a  portion  of  the  wire  from  A  to  C  returning  to  its  original 
position;  and  in  order  for  it  to  return  to  its  original  position,  owing  to 
the  dead  bend  between  A  and  B,  the  canine  B  must  be  rotated  according 
to  the  position  shown  in  the  dash  line. 

If  we  should  desire  to  tip  the  crown  distally  and  the  apex  mesially  or 
forward,  it  can  be  accomplished  by  means  of  the  pinched  wire  and  using 


REGULATING   APPLIANCES  219 

the  pliers  as  illustrated  in  Fig.  271.  In  this  ease  the  beaks  of  the  pliers 
A  are  placed  in  the  position  shown  at  1  and  as  the  pinch  is  made,  the 
handles  of  the  pliers  are  rotated  gingivally,  which  results  in  a  dead  bend 
between  A  and  B,  and  an  active  torsional  spring  between  A  and  C.  As 
the  active  spring  returns  to  its  original  shape  and  as  the  point  between 
.1  and  B  is  a  dead  bend,  the  canine  B  is  made  to  assume  the  position 
shown  by  the  dotted  line.  An  opposite  force  is  exerted  on  the  other 
end  of  the  appliance  C  which  has  a  tendency  to  change  the  canine  C 
in  the  opposite  direction  to  B.  In  considering  the  possibilities  of  tooth 
movements  as  a  result  of  the  torsional  spring,  one  can  readily  see  what 
a  large  amount  of  harm  can  be  done  when  an  operator  produces  a  tor- 
sional spring  in  the  alignment  wire  unknowingly.  In  using  a  lingual 
alignment  wire,  which  has  the  bands  upon  the  molars,  it  must  be  remem- 
bered that  tipping  of  the  molars  bueeo-lingually  can  be  very  easily  ac- 
complished by  making  pinches  in  a  certain  position  of  the  alignment 
wire  and  by  producing  certain  movements  of  the  wire-stretching  pliers 
during  this  pinching. 

In  Fig.  272  the  heavy  black  line  represents  a  lingual  alignment  wire 
which  has  been  soldered  to  molar  bands  and  the  original  position  of  the 
molars  is  represented  by  the  black  perpendicular  line.  Now,  if  the 
wire-stretching  pliers  A  are  placed  in  the  position  shown  at  1  and  as  the 
pinch  is  made,  the  pliers  are  moved  gingivally  but  not  rotated,  the  result 
will  be  a  change  in  the  shape  of  the  incisal  section  as  represented  by  the 
dash  line,  which  will  produce  a  twist  or  a  torsional  spring  in  the  pre- 
molar section  represented  by  the  arrow-.  As  a  result  of  this  torsional 
spring  in  the  premolar  section,  the  occlusal  portion  of  the  molars  will 
be  tipped  lingually  and  the  apices  will  have  a  tendency  to  move  buccally. 
In  making  this  pinch  and  movement  of  the  wire-stretching  pliers  as 
shown  from  Al  to  A2,  the  incisal  section  will  assume  a  V-shape  that  is 
illustrated  by  the  dash  line.  This  bend  in  the  incisal  section  will  also 
have  a  tendency  to  narrow  the  lingual  alignment  wire  in  the  canine  re- 
gion. In  order  to  overcome  this  lingual  narrowing  in  the  canine  region, 
if  it  is  desirable  to  at  the  same  time  produce  expansion  of  the  canines,  a 
series  of  small  straight  pinches  must  be  made  in  the  incisal  portion  of  the 
arch  to  produce  expansion  which  will  overcome  the  narrowing  of  the 
lingual  wire  produced  by  the  gingival  bend  from  1  to  2  at  A. 

Fig.  273  shows  the  possibility  of  tipping  the  occlusal  surface  of  the 
molars  buccally  and  the  apices  lingually  by  making  the  reverse  move- 
ments as  shown  in  Fig.  272.  In  this  case,  the  wire-stretching  pliers 
grasps  the  incisal  portion  of  the  lingual  wire  at  1  and  as  the  pinch  is 
made  the  wrire  is  carried  occlusally,  which  has  a  tendency  to  change  the 


220 


PRACTICAL    ORTHODONTIA 


incisal  section  of  the  wire  as  represented  by  the  dash  line  and  thereby 
produce  torsion  upon  the  premolar  section  as  indicated  by  the  arrows. 
This  force  moves  the  occlusal  surface  of  the  molars  buccally  and  the 
apices  lingually.  While  it  is  possible  to  rotate  the  molars  by  making 
a  pinch  and  bend  in  the  incisal  region  as  shown  in  Fig.  273,  it  is  pref- 
erable, if  the  rotation  of  the  molars  is  desired,  to  produce  that  rota- 
tion by  means  of  making  a  pinch  in  the  premolar  region,  as  shown  in 
Fig.  274.    Such  change  as  produced  in  the  alignment  wire  in  Figs.  272 


Fig.  272. 


Fig.   273. 


and  273  will  produce  a  rotation  or  tipping  of  both  molars,  while  such  a 
pinch  as  made  in  Fig.  274  will  produce  a  buccal  or  lingual  movement  of 
only  one  molar  and  produces  this  movement  without  the  tendency  of  any 
change  in  the  shape  of  the  alignment  wire  in  the  incisal  region.  In  Fig. 
274  we  again  have  the  alignment  wire  represented  by  the  heavy  black 
line  and  the  original  position  of  the  molars  represented  by  the  heavy 


Fig.  274. 


Fig.  275. 


black  lines.  The  wire-stretching  pliers  is  placed  at  point  A  in  the  first 
position  represented  by  1,  and  as  the  pinch  is  made,  the  handle  of  the 
pliers  is  rotated  occlusally  to  position  2  as  shown  by  the  dotted  outline. 
The  direction  of  the  movement  is  represented  by  the  heavy  arrow.  As  a 
result  of  this  movement  of  the  wTire-stretching  pliers  a  dead  bend  is 
produced  in  the  wire  between  A  and  B.  All  through  the  remaining 
portion  of  the  lingual  wire  from  A  around  through  the  incisal  section 
and  the  premolar  section  of  C,  we  have  an  active  spring  which  tends  to 


REGULATING    APPLIANCES 


221 


return  to  its  original  position.  As  the  alignment  wire  from  A  to  C, 
which  possesses  the  active  spring  produced  by  the  pinch  and  movement 
of  the  pliers  from  1  to  2  returns  to  its  original  position,  the  molar  B  is 
tipped  as  shown  by  the  dash  line  which  is  a  rotation  of  the  crown  lin- 
gually and  the  apices  buccally. 

If  a  reverse  movement  of  the  molar  is  desired,  or  a  movement  where 
the  crown  is  moved  buccally  and  the  apices  are  tipped  lingually,  it  will 


EX 


Fig.  276. 


be  possible  to  produce  that  movement  by  placing  the  wire-stretching 
pliers  at  the  position  1  as  shown  in  Fig.  275,  and  as  the  pinch  is  made, 
the  handles  are  moved  gingivally  to  the  position  shown  at  2.  This  again 
results  in  a  dead  bend  between  A  to  B  and  an  active  spring  between  A 
and  C.  As  the  alignment  wire  .from  A  to  C  returns  to  its  original  shape, 
the  crown  of  molar  B  will  be  tipped  buccally,  and  the  apices  will  be 
tipped  gingivally  or  lingually.     Fig.  276  shows  the  possibility  of  pro- 


,,/**- 


ducing  a  tipping  of  the  crown  of  the  molar  buccally  by  means  of  pro- 
ducing a  torsional  spring  in  the  premolar  section  of  the  alignment  wire 
by  the  proper  use  of  the  wire-stretching  pliers.  In  addition  to  this  tip- 
ping of  the  crown  of  the  molar  buccally  by  making  a  pinch  in  the  incisal 
section  of  the  arch  as  shown  in  Fig.  276  at  D  at  the  section  El  will  be 
lengthened  to  E2,  thereby  producing  a  lateral  extension  of  the  premolars 
and  molars.     The  pinch  made  at  A  while  the  handles  of  the  pliers  are 


222  PRACTICAL   ORTHODONTIA 

moved  gingivally  will  result  in  a  torsional  bend  which  will  move  the 
crown  of  the  right  molar  buccally,  while  the  pinch  at  D  will  carry  both 
molars  buccally,  but  the  one  on  the  left  side  will  be  carried  buccally 
without  any  occlusal  tipping. 

In  some  instances,  it  is  desired  to  produce  an  elevation  of  one  of  the 
molars  which  can  be  accomplished  according  to  the  illustration  Fig.  277. 
By  placing  the  beaks  of  the  wire-stretching  pliers  in  the  incisal  section 
at  1  and  rotating  the  handles  gingivally  to  2,  there  will  be  produced  a 
torsional  spring  in  the  alignment  wire  which  will  result  in  a  change  of 
the  right  side  of  the  wire  from  the  straight  section  shown  at  MR  to  the 
dash  line.  In  other  words,  the  molar  on  the  right  side  will  be  elevated 
and  there  will  be  an  equal  tendency  for  the  molar  on  the  left  side  to 
be  depressed,  but  owing  to  the  difference  of  resistance,  no  movement  of 
the  left  molar  will  occur. 

The  wire-stretching  pliers  and  lingual  wire  present  great  mechanical 


Fig.  278. — Lingual  arches  showing  different  styles  of  application.      (L,ourie.) 

possibilities  and  provide  a  force  which  is  capable  of  moving  teeth  in  many 
directions  if  properly  applied.  It  must  also  be  remembered  that  in 
using  the  lingual  arch,  every  pinch  on  the  wire  will  produce  some  move- 
ment and  this  movement  will  not  be  noticeable  until  a  certain  length 
of  time  has  elapsed. 

The  position  of  the  lingual  arch  will  vary  according  to  the  type  of 
tooth  movement  that  is  to  be  desired.  Fig.  278  shows  the  soldered 
lingual  arch  on  the  upper  and  lower  teeth.  In  the  lower  dental  appa- 
ratus the  lingual  wire  is  so  adjusted  that  the  pressure  can  be  brought  to 
bear  on  the  lateral  halves  of  the  dental  arch  and  on  the  incisors  by 
pinching  and  lengthening  the  wire.  The  lingual  wire  on  the  upper 
teeth  is  adjusted  for  the  purpose  of  expanding  the  right  half  of  the 
dental  arch  that  was  in  lingual  occlusion  to  the  lower  teeth.  It  will  be 
seen  that  the  lingual  wire  on  the  left  side  rests  against  all  of  the  teeth, 


REGULAT1  NG    APPLIANCES 


223 


but  on  the  right  side,  the  only  tooth  which  is  receiving  any  force  at  the 
present  time  is  the  molar  to  which  the  lingual  wire  is  attached.  Spurs 
are  soldered  to  the  upper  lingual  wire  at  such  point  that  they  engage 
the  mesial  portion  of  the  canine.    These  spurs  can  be  bent  distally  and 


F:g.    279.  Fig.    280. 

Spurs    used   on    lingua!   wire    for    the    purpose    of   changing   relation    of   incisors.      (Lourie.) 

can  be  made  to  keep  the  deciduous  canines  against  the  deciduous  molars. 
The  spurs  and  finger  springs  used  iu  conjunction  with  the  soldered 
Lingual  wire  make  possible  many  different  forms  of  tooth  movement. 
Spurs  can  be  made  to  tit  against  the  gingival  portions  of  the  teeth 
which  will  allow  the  lingual  wire  to  be  away  from  the  proximal  spaces 
thereby  permitting  the  food  to  pass  out  of  the  proximal  space  without 
catching  on  the  appliance.  The  gingival  spurs  are  made  by  filing  the 
end  of  a  wire  flat  and  allowing  the  chisel-shaped  end  of  the  wire  to 


281. 


Fig.    282. 


rest  against  the  tooth.  Care  must  be  used  in  selecting  the  point  on  the 
tooth  against  which  the  spur  presses  in  order  not  to  produce  elongation 
or  depression  of  some  of  the  teeth.  Fig.  279  shows  a  lingual  wire  which 
occupies  a  gingival  position  and  spurs  and  finger  springs  are  used  to  ex- 


224 


PRACTICAL    ORTHODONTIA 


ert  pressure  on  the  teeth.  Pressure  is  exerted  labially  on  the  canines 
by  means  of  two  finger  springs  that  are  made  from  elastic  gold.  The 
flattened  spurs  are  seen  pressing  against  the  centrals  and  lateral  incisors, 
which  teeth  must  be  adjusted  in  the  plane  of  occlusion.  The  spurs  on 
the  centrals  rest  on  a  point  occlusal  to  the  gingival  marginal  ridge 
and  the  spurs  on  the  laterals  are  at  a  point  gingival  to  the  gingival 
margin  ridge.  By  bending  the  spurs,  pressure  can  be  exerted  on  the 
central  and  laterals  in  such  a  manner  as  to  produce  a  change  in  the 
occlusal  plane  as  is  indicated  by  Fig.  280. 

The  finger  spring  can  also  be  used  on  the  lingual  arch  for  the  purpose 
of  moving  a  tooth  labially  that  is  in  linguoversion.  Fig.  281  shows  the 
construction  of  the  soldered  lingual  wire  with  the  finger  spring  resting 
against  the  incisor  that  is  in  linguoversion.  By  using  the  wire-stretch- 
ing pliers  the  lingual  wire  can  be  made  to  produce  expansion  of  the  entire 
dental  arch.    Finger  springs  soldered  to  the  lingual  wire  can  be  used  to 


Fig.  283. 


Fig.  284. 


an  advantage  in  the  treatment  of  impacted  teeth.  They  are  made  from 
22-gauge  elastic  gold  soldered  to  the  lingual  wire,  the  free  end  of  the 
spring  made  into  an  eyelet,  and  attached  to  the  impacted  tooth  by 
means  of  a  ligature.  Fig.  282  shows  lingual  wire  with  two  finger 
springs  for  the  correction  of  two  impacted  canines.  In  those  cases  of 
malocclusion  where  the  upper  arch  is  contracted  and  the  canines  are  in 
labioversion  the  lingual  arch  with  finger  springs  extending  over  the 
canines  makes  a  very  effective  and  inconspicuous  appliance.  Fig.  283 
shows  such  a  case  with  the  appliance  in  place.  Plain  bands  are  made 
for  the  molar  and  the  lingual  wire  should  be  19-gauge  iridioplatinum 
so  it  can  be  pinched  with  the  wire-stretching  pliers  for  the  purpose  of 
expanding  the  dental  arch.  The  finger  springs  which  engage  the  canines 
are  made  from  22-gauge  elastic  gold  and  in  fitting  them  to  the  canines 


REG1  LATINO   APPLIANCES 


225 


the  finger  springs  can  be  more  easily  adjusted  if  the  bends  can  be 
made  as  nearly  right  angle  bends  as  possible.  It  has  been  found  that 
such  a  bend  can  be  more  easily  adjusted  than  one  that  is  curved  or 
more  nearly  follows  the  contour  of  the  tooth.  Fig.  284  shows  the 
canines  in  position  as  a  result  of  the  pressure  from  the  finger  springs. 
The  lingual  arch  soldered  to  the  molar  bands  makes  a  very  secure 
attachment  and  offers  great  possibilities  in  anchorage.  In  those  cases 
where  we  require  expansion  of  only  one  side  of  the  dental  arch  the 
lingual  wire  is  soldered  to  the  molar  band  and  the  other  side  is  placed 
in  a  short  parallel  tube.  Fig.  285  shows  a  case  in  which  one  molar 
is  in  lingual  relation  to  the  lowers  and  the  other  one  is  in  normal 
position.  Fig.  286  shows  the  occlusal  view  of  the  model  with  the 
appliance  in  place.  By  using  a  short  tube  on  the  malposed  molar 
and  by  having  the  lingual  wire  occupying  a  position  lingua  Uy  to  the 


Fig.   285. 


incisors,  it  is  possible  to  remove  lb;'  lingual  wire  from  the  tube  and 
increase  the  expansion  of  the  same.  Owing  to  the  fact  that  this 
form  of  lingual  arch  moves  the  tooth  by  elastic  expansion,  spring 
gold  makes  the  most  satisfactory  appliance.  In  the  case  shown  in  Fig. 
285  the  protrusion  of  the  anterior  teeth  was  corrected  by  means  of  the 
high  labial  arch  and  finger  springs.  Other  uses  of  the  soldered  lingual 
arch  as  well  as  the  high  labial  arch  will  be  shown  under  treatment. 

In  his  technique,  Mershon  employs  a  form  of  attachment  that  enables 
the  operator  to  remove  the  lingual  arch  or  wire  and  bend  it  outside  of 
the  mouth  in  order  to  get  the  necessary  force  on  the  teeth.  A  plain  band 
is  fitted  to  the  anchor  tooth,  the  technique  of  making  which,  according  to 
Mershon,  is  described  on  page  171.  To  the  lingual  side  of  the  anchor 
band  is  soldered  a  half-round  tube,  which  is  about  .10  inch  in  length, 


226 


PRACTICAL    ORTHODONTIA 


as  shown  in  Figs.  287  and  288.  These  bands,  which  are  made  over 
models  in  Figs.  194,  195  and  196,  are  then  placed  on  a  full  model  of 
the  dental  apparatus,  as  shown  in  Fig.  289.  The  construction  of  the 
lingual  arch  is  begun  by  soldering  a  half-round  spur  .9  inch  in  length 
on  a  piece  of  19-gauge  wire.  The  premolar  section  of  the  arch  extends 
forward  to  the  region  of  the  mesial  surface  of  the  first  premolar  or 
thereabouts.  It  is  bent  to  fit  the  irregularities  of  the  lingual  surfaces 
of  the  teeth,  as  they  occupy  positions  of  malocclusion,  as  shown  in  Fig. 


Fig.   287. 


Fig.  28S. 

Figs.  287  and  288. — Bands  with  half-round  tubes  for  use  with   Mershon's  lingual  alignment  wire. 

(Mershon.) 

290.  After  the  premolar  sections  are  fitted,  the  next  step  is  to  fit  the 
incisor  section,  as  shown  in  Fig.  291.  This  section  is  also  bent  to  follow 
the  teeth  as  they  set  in  positions  of  malocclusion  and  is  made  long 
enough  so  that  the  distal  ends  will  touch  the  mesial  ends  of  the  pre- 
molar sections.  The  incisal  section  is  fitted  to  the  lingual  surfaces  of 
the  teeth  at  a  point  slightly  occlusal  to  the  gingival  marginal  ridge. 
The  ends  of  the  premolar  sections  and  the  incisal  sections  should  meet 
so  as  to  form  a  square  end-to-end  joint,  as  shown  in  Fig.  292. 


REGULATING  APPLIANCES 


227 


This  technique  of  making  a  lingual  arch  in  three  sections  is  employed 
because  the  lingual  wire  is  easier  to  adapt  in  three  pieces  than  it  is  to 
handle  it  as  a  single  piece  in  attempting  to  make  it  conform  to  the  irregu- 
larities of  the  teeth.  The  appearance  of  the  different  sections  is  shown 
in  Fig.  293.  In  order  to  prevent  the  arch  from  being  displaced  and  to 
keep  the  half-round  spur  in  the  half-round  tube,  a  piece  of  wire  of 
about  22-gauge  is  soldered  to  the  lingual  arch  mesial  to  the  half-round 
spur,  as  shown  on  the  right  side  of  Fig.  294.    This  lock  is  a  modification 


Fig.    289. — Bands   placed    on   model    of  mouth.      (Mershon.) 


Fig.    290. — Model   showing  construction    of  premolar  section    of  lingual   wire.      (Mershon.) 


of  what  has  been  known  in  literature  for  the  last  few  years  as  the 
Young-Angle  lock,  though  similar  locks  were  used  by  Barnes  a  great 
many  years  previously.  The  locking  devices  that  are  soldered  only  on 
one  end  are  easily  bent  and  consequently  irritate  the  tongue.  To  avoid 
that  trouble,  Burrill  has  devised  a  lock  soldered  to  each  side  of  the  spur 
that  contains  a  coiled  spring.  This  greatly  increases  the  stability  of 
the  lock,  which  is  shown  in  Fig.  295. 

The  completed  lingual  arch  is  shown  in  place  in  Fig.  296,  which  also 


228 


PRACTICAL    ORTHODONTIA 


shows  that  one  of  the  locks  is  bent  under  the  half -round  tube  to  prevent 
it  from  coining  out,  and  that  the  lock  of  the  left  side  has  not  been  bent 
into  position. 

Dr.   Mershon  has   described   a   technique   of   making  the   removable 


11. — Incisal  section  of  lingual  arch   fitted       Fig.     292. — Incisal     anil     premolar     section     in 
to    teeth.       (Mershon.)  place    ready    for    soldering.      (Mershon.) 


Fig.     293. — Incisal    and    premolar    sections     re- 
moved   from    model.       (Mershon.) 


Fig.    294. — Sections   of   lingual   wire   soldered 
er,    showing  locking   device.      (Mershon.) 


Fig.   295. — Lock  for   use   with   perpendicular   tube   on   molar   band.      (Burrill.) 


lingual  arch  from  one  piece  of  wire,  which  is  made  according  to  the 
following  plan:*  "Start  at  the  half-round  tube  (on  the  molar  band), 
allowing  the  arch  wire  to  extend  about  one  eighth  of  an  inch,  distally 
beyond  the  tube.     Just  mesial  to  the  tube  we  make  a  compound  bend 


*The   Removable   Lingual   Arch  as  an   Appliance   for  the   Treatment   of   Malocclusion,   by   John 
V.    Mershon,    International   Journal   of    Orthodontia,    iv,    Xo.    11,   p.    578. 


REGULATING   APPLIANCES 


229 


in  the  wire,  first  to  the  gingiva,  then  again  bending  the  wire  parallel 
with  the  gingiva,  and  continuing  along  the  lingual  surfaces  of  the 
teeth,  as  close  to  the  gingiva  as  possible,  without  impinging  on  it.  adapt- 
ing the  wire  to  all  the  irregularities  of  the  denial  arch,  until  the  tube 
is  reached  on  the  anchor  band  on  the  opposite  side,  when  the  arch  is 
cut  off  one-eighth  of  an  inch  distal  to  the  tube.  The  tubes  should  he 
placed  on  the  lingual  surface  of  the  anchor  bands,  usually  in  the  center 
of  the  band  mesio-distally  in  both  upper  and  lower  jaws.  In  the  lower 
they  should  be  placed  as  near  the  occlusal  edge  of  the  band  as  possible, 
allowing  only  sufficient  distance  between  the  occlusal  edge  of  the  band 
and  the  top  of  the  tube  for  the  arch.  This  is  so  placed  for  the  reason 
that  the  post  is  easier  to  place  in  the  tube  if  it  is  not  too  far  toward 
the  gingiva,  as  it  is  difficult  to  see  the  tube  in  the  lower  on  account  of 
the  tongue  and  saliva.      In  the  upper  jaw.  the  tube  should  occupy  the 


Fig.   2'J6. — Completed   lingual   arch    in    position    on    model.      (Mershon.) 


same  position  mesio-distally,  but  should  be  placed  as  near  the  gingiva 
as  possible,  otherwise  the  lingual  cusps  of  the  lower  molars  will  come 
in  contact  with  the  arch,  and  the  continuous  biting  on  it  will  eventually 
cause  the  arch  to  break.  The  post  consists  of  a  half-round  wire  soldered 
to  the  arch  and  accurately  fitting  the  half-round  tubes  forming  a  por- 
tion of  the  lock.  For  convenience  in  soldering,  a  long  piece  of  half- 
round  wire  is  selected.  Place  the  arch  accurately  on  the  model,  mark 
the  arch  opposite  the  tubes,  then  solder  the  post  to  the  arch  opposite 
the  mark,  in  the  usual  free-hand  manner,  cutting  off  the  half-round 
wire  just  a  little  shorter  than  the  tube,  leaving  a  catch  for  the  lock- 
wire.  Then  place  the  half-round  post  wire  in  the  tube  on  the  molar 
bands  on  the  model.  If  the  arch  should  not  lie  correctly  on  the  model, 
remove  it,  and  with  two  pairs  of  the  Young  pliers  it  can  be  twisted  to 
the  desired  position.     Proceed  in  the  same  manner  soldering  the  half- 


230 


PRACTICAL    ORTHODONTIA 


round  post  wire  on  the  opposite  side.  The  arch  is  again  replaced  on 
the  model  with  both  pieces  of  the  half-round  post  wire  in  the  tubes.  If 
the  arch  should  not  be  well  adapted  or  be  raised  away  from  the  model, 
direct  the  flame  of  the  blow  pipe  on  the  arch,  heating  it  to  a  cherry 
red,  and  while  hot,  pressing  with  a  suitable  instrument  on  the  arch 
it  can  be  readily  adapted  to  the  model.  The  lock  consists  of  a  wire 
of  suitable  size,  soldered  to  the  gingival  surface  of  the  arch,  twenty 
one-lmndredths  of  an  inch  mesial  to  the  half-round  post  passing  it  dis- 
tally  to  catch  under  the  gingival  surface  of  the  tube,  thereby  preventing 


Fig.   297.      (Mershon.) 


Fig.   29S.      (Mershon.) 


the  post  coming  out  of  the  tube.  After  polishing,  the  arch  is  now  ready 
to  place  in  the  mouth.  Remove  the  anchor  bands  from  the  plaster 
model  and  cement  them  on  the  teeth.  In  trying  the  arch  in  the  mouth, 
grasp  the  arch  on  the  left  side  in  the  region  of  the  half-round  post, 
with  a  pair  of  How  pliers,  and  place  the  post  in  the  tube  on  the  left 
side.  The  arch  should  lie  in  its  proper  position,  with  the  half-round 
post  on  the  opposite  side  parallel  with  the  half-round  tube.  Should  it 
not  fit  properly  (Fig.  297),  twist  or  bend  the  arch  until  it  lies  correctly. 
Remove  the  post  from  the  tube  on  the  left  side,  then  place  post  on  the 


REGULATING    APPLIANCES 


231 


right  side  in  the  tube.    If  the  post  on  the  left  side  drops  in  place  in  the 
tube,  then  the  arch  is  ready  to  be  locked  in  place  (Fig.  298)." 

Owing  to  the  accuracy  with  which  the  half-round  spurs  fit  the  half- 
round  tubes  and  to  the  large  amount  of  elasticity  that  is  obtained  from 
this  type  of  appliance,  great  care  must  be  observed  in  adjusting  it  cor- 
rectly in  order  to  avoid  unnecessary  pain  and  discomfort  to  the  patient 
and  also  to  avoid  the  displacement  of  the  molar  teeth.  The  spurs  are 
placed  in  the  half-round  tubes  without  any  pressure  at  first.  When 
the  appliance  is  removed  for  bending  in  order  that  pressure  may  be 


Fig.   299. — Calipers  suggested  by  Dr.   C.   A.   Hawley. 


m 

'  y 

Fig.  300. — Hawley's  calipers  used  in  the  measurement  of  lingual  arch  between  molars.     (Mershon.) 


exerted  on  the  teeth,  a  careful  measurement  is  made  of  the  distance 
between  the  half-round  spurs  by  using  a  pair  of  calipers,  as  shown  in 
Fig.  299.  These  calipers  were  suggested  by  Hawley  for  measuring  the 
mesio-distal  diameter  of  teeth,  and  are  very  useful  in  adjusting  the 
lingual  arch.  After  the  measurement  has  been  obtained,  the  calipers  are 
set  at  that  point  and  the  changes  are  made  in  the  bends  of  the  arch  to 
exert  force  on  the  irregular  teeth,  after  which  the  distance  between  the 
molars  is  checked  up  with  the  calipers,  as  shown  in  Fig.  300. 

In  using  the  removable  lingual  arch,  it  must  be  remembered  that 


232 


PRACTICAL    ORTHODONTIA 


Eorce  can  be  exerted  upon  the  teeth  in  three  different  ways:  first  by 
straightening  out  the  bends  and  curves  in  alignment  wire  which  are 
produced  when  the  arch  is  fitted  to  the  irregularities  of  teeth;  second 
by  pinching  the  wire  in  the  straight  portions  of  the  alignment  wire  in 
order  to  lengthen  it;  and  third  by  the  use  of  elastic  finger  springs. 
In  pinching  the  lingual  wire  with  the  wire-stretching  pliers  to  lengthen 
it,  we  use  the  same  principle  as  applied  in  the  soldered  lingual  arch, 
which  has  been  described  previously.  The  other  methods,  those  of 
straightening  out  the  bends  in  the  lingual  arch  so  it  exerts  pressure  on 
the  malposed  teeth,  and  the  use  of  finger  springs,  have  been  worked  out 
by  Dr.  Mershon.     Finger  springs  can  be  used  to  exert  pressure  on  one 


Fig.    301. — Extension    spring   soldered    on    lingual   arch    to    increase    action    on    tooth.      (Mershon.) 


Fig.    302.      (  Mershon  ) 


or  more  teeth  and  thereby  give  a  greater  range  of  elasticity  than  is 
possible  with  a  plain  lingual  arch.  These  finger  springs  can  be  made  to 
exert  pressure  on  one  or  more  teeth,  and  are  attached  to  the  lingual 
wire  as  shown  in  Fig.  301.  Such  finger  springs  are  generally  placed 
on  the  gingiva]  side  of  the  lingual  alignment  wire,  and  are  made  of 
spring  gold  which  exerts  a  delicate  and  positive  force  upon  the  teeth. 
These  finger  springs  can  also  be  shaped  for  the  purpose  of  moving 
teeth  mesially  or  distally  as  is  shown  in  Fig.  302  where  the  pressure  is 
exerted  on  the  first  premolar  for  the  purpose  of  moving  it  distally  and 
also  correcting  torsiversion.     By  extending  the  finger  springs  over  the 


KEGULATIXG    APPLIANCES 


233 


occlusal  embrasure  of  the  teeth,  pressure  can  be  brought  to  bear  on  the 
labial  side  of  the  tooth  and  correct  torsiversion  without  the  use  of  bands 
and  ligatures.  Such  an  application  of  the  finger  spring  is  shown  in 
Pigs.  303  and  304. 

In  certain  types  of  malocclusion  where  it  is  desirable  to  move  a  tooth 
lingually  and  also  rotate  it,  it  may  be  necessary  to  employ  the  use  of 
a  band  with  an  auxiliary  finger  spring  as  is  shown  in  Fig.  305.  We  also 
find  that  finger  springs  are  very  useful  in  opening  space  for  impacted 
teeth,  and  in  such  instances  it  becomes  necessary  to  employ  two  finger 
springs  as  shown  in  Pig.  306.     These  finger  springs  are  soldered  to  the 


i  Mershon.) 


504.      (Mershon.) 


areh  the  width  of  a  tooth  distal  to  the  place  you  wish  to  open  up  and 
the  other  one  soldered  the  width  of  a  tooth  mesial  to  the  space,  thereby 
making  two  springs  which  work  in  opposite  directions  and  which  open 
up  the  space  for  the  impacted  tooth.  The  spring  which  is  most  distal  is 
curved  mesially  to  engage  one  tooth,  while  the  spring  which  is  mesial, 
is  curved  distally  to  engage  the  other  tooth.  These  springs  have  the 
ends  flattened  if  necessary  to  go  into  the  proximal  space  and  conse- 
quently exerting  pressure  in  opposite  directions  becomes  a  form  of  re- 
ciprocal anchorage  which  is  very  valuable  in  this  type  of  tooth  move- 
ment. These  finger  springs  are  made  of  a  material  that  possesses  a  great 
amount  of  elasticity,  known  as  high  fusing  clasp  metal  or  elastic  gold 


234 


PRACTICAL    ORTHODONTIA 


of  about  22  gauge.  They  should  be  soldered  to  the  lingual  base  wire 
with  a  low  fusing  solder  in  order  to  avoid  overheating  which  destroys 
the  elastic  metal,  and  makes  the  finger  spring  break  quite  easily.  By 
employing  the  finger  springs  it  is  possible  to  correct  much  more  com- 
plicated malocclusions  than  could  be  corrected  by  using  the  lingual 
arch  alone.  In  using  the  removable  lingual  arch  the  half-round  post 
which  engages  the  half-round  tube  on  the  molar  band  makes  possible 


Fig.   305.      (Mershon.) 


Fig.   306.      (Mershon.) 


any  type  of  molar  movement  or  rotation  that  is  desirable,  by  simply 
bending  the  alignment  wire  in  such  a  manner  as  to  change  the  direction 
in  which  the  half-round  post  goes  into  the  tube.  In  fact,  in  adjusting 
the  removable  lingual  alignment  wire  great  care  must  be  exercised  in  us- 
ing the  half-round  post  to  always  have  it  fit  accurately  in  exactly  the 
manner  desired  or  the  molar  will  sometimes  be  rotated  into  undesirable 
positions. 

Appliances  for  the  Bodily  Movement  of  Teeth 

Appliances  designed  for  the  bodily  movement  of  teeth  have  been  used 
for  many  years.  One  of  the  early  types  has  been  described  by  Case 
under  the  name  of  the  contouring  appliance.  Since  that  time  different 
styles  have  been  placed  on  the  market  that  possess  more  or  less  value. 


REGULATING    APPLIANCES 


235 


The  principle  embodied  in  all  types  of  appliances  for  the  bodily  move- 
ment of  teeth,  or  the  movement  of  the  apex  more  than  the  crown,  or 
the  movement  of  the  crown  in  one  direction  and  the  root  in  the  other. 
is  that  of  two-point  attachment. 

Case's  appliance  consists  of  two  arches  or  wires  that  are  so  attached 
to  the  teeth  that  one  will  exert  force  at  one  point  in  one  direction  and 
the  other  will  exert  force  at  another  point  in  the  opposite  direction. 

An  appliance  for  the  bodily  movement  of  teeth  has  been  suggested  by 
Angle,  and  called  the  pin  ami  tube  appliance.  It  consists  of  small  gauge 
tubes  soldered  to  bands  that  are  placed  on  the  teeth  to  be  moved.  The 
alignment  wire  is  of  small  gauge,  .03  inch  in  diameter,  which  gives  great 


Fig.  307. — Angle's  pin  and  tube  appliance.     (Ketcham.) 


elasticity.  The  small  pins  that  engage  the  tubes  on  the  bands  are 
soldered  to  the  alignment  wire  with  hard  solder,  and  care  must  be  em- 
ployed to  avoid  overheating  of  the  parts.  If  too  much  solder  is  used. 
the  pin  will  not  properly  engage  the  tube.  A  catch  is  made  on  the 
gingival  end  of  the  pin  to  engage  the  gingival  part  of  the  tube.  The 
band  should  be  sufficiently  wider  than  the  length  of  the  tube  so  that  there 
will  be  enough  width  of  band  occlusally  to  the  tube  for  the  arch  to  lie  on, 
thus  keeping  it  from  contact  with  the  tooth.  Fig.  307  shows  the  Angle 
appliance  in  place  on  the  teeth.  To  enable  the  parallel  tubes  to  be  used 
with  the  perpendicular  tubes  on  the  molar  bands,  the  arch  is  made  in 
three  sections — the  screw  sections  and  the  middle  section.     The  screw 


236 


PRACTICAL    ORTHODONTIA 


sections  and  the  middle  section  have  telescoping  ends,  as  shown  in 
Fig.  307. 

The  use  of  the  pin  and  tube  in  conjunction  with  a  small  labial  wire 
of  .022.1  inch  has  been  described  by  Suggett,*  as  follows: 

"Take  a  piece  of  wire,  of  platinum-gold,  about  six  inches  long,  and 
with  pliers  (Fig.  308)  bend  the  end  as  shown  in  Pig.  309.  Then  place 
this  right  angle  in  the  left  molar  tube,  and  after  getting  the  length  of 


Fig.   308. — Sharp-nosed  pliers   for  bending   .022?   wire.      (Suggett.) 


the  loop,  make  a  scratch  on  the  wife  to  indicate  where  the  next  pin 
should  be  soldered  (Fig.  310).  Pins  3-16  inch  long,  cut  from  the  same 
.022;")  wire,  with  a  small  sliver  of  16  karat  gold  solder  melted  to  one  end. 
should  be  at  hand  ready  for  use.  Dip  the  end  of  this  pin  in  flux,  and 
solder  it  to  the  wire  as  indicated  by  the  scratch.     A  jig,  or  any  other 


Fig.   309. — After  first  bend   is  mai 


R 


Fig.    310. — Second    step.      (Suggett.) 


(  Suggett.  i 


n 


mechanical  apparatus,  is  absolutely  unnecessary,  unless  the  operator  is 
rather  shaky.  The  jig  was  thought  to  be  necessary  when  using  the  stiff 
.030  wire,  which  was  too  rigid  to  bend  and  adjust  if  the  pin  was  not 
absolutely  in  the  correct  position.  In  making  the  loop  just  distal  to  the 
cuspid,  shape  it  so  that  it  will  act  as  a  hook  for  the  intermaxillary  an- 
chorage. Either  do  this,  or  solder  a  small  piece  of  wire  for  this  purpose. 
Make  your  next  loop  and  get  your  measurement  for  the  next  pin,  as 


*Suggett,  A.   H. :     The  Use  of  .0225   Alignment   Wire,   Internationa]   Journal   of  Orthodontia, 

February,   1917,  vol.    iii,   p.    105. 


REGULATING    APPLIANCES 


237 


before,  but  provide  for  the  rotation  of  the  centrals  and  laterals  as  shown 
in  Figs.  311  and  312,  where  the  loop  rests  on  the  mesial  corner  of  these 
teeth.  After  boiling  the  appliance  and  slightly  bending  the  pins  so 
that  they  will  bind  in  the  tubes,  and  shaping  it  to  as  near  an  ideal  curve 
as  practicable,  it  is  ready  to  slip  in  place.    There  is  no  need  of  adjust- 


ing. 311. 


Fig.   312.  Fig.   313. 

Figs.   311,   312  and  313.      Adjustment   of  .0225   alignment   wire.      (Suggett.) 


Fig.   314. — Upper  alignment   wire  .0225   adjusted  to   upper   arch.      (Suggett.) 


ing  it  again  for  several  months,  and  possibly  not  at  all,  for  there  are 
the  hooks  for  intermaxillary  anchorage,  the  spring  for  the  necessary  ex- 
pansion, and  the  upward  spring  necessary  to  carry  the  incisors  upward 
and  reduce  the  excessive  overbite,  as  shown  in  Fig.  312.  In  attaching 
the  lower,  the  close  bite  of  the  molars  presents  another  problem.     The 


238  PRACTICAL    ORTHODONTIA 

pins  and  tubes  are  indicated,  but  it  is  an  ideal  place  for  the  Robinson 
attachment,  which  requires  less  vertical  room  (Fig.  312).  The  molar 
bands  are  fitted  just  as  the  upper  molar  bands  were,  with  lingual  spurs 
to  carry  out  the  deciduous  molars.  All  the  other  teeth  on  the  lower 
arch  are  banded  and  tubed,  and  the  wire  and  tubes  adjusted  just  the 
same  as  on  the  upper,  except  for  the  Robinson  attachment  on  the  molars, 
and  that  the  wire  is  not  sprung  in  to  attach  to  the  right  lateral,  but  a 
rubber  is  looped  over  it  until  it  is  a  little  nearer  the  line,  when  the  pin 
can  be  slipped  into  the  tube  and  the  root  movement  is  made  in  unison 
with  the  others  (Fig.  313).  A  hook  for  intermaxillary  anchorage  is 
soldered  on  the  wire  just  anterior  to  the  molar  attachment,  and  this  arch 
wire  is  ready  to  slip  into  place  (Fig.  312).  Fig.  314  shows  the  occlusal 
view  of  the  upper." 

The  use  of  small  gauge  wire  for  the  bodily  movement  of  teeth  was 
advocated  by  Robinson*  and  described  in  clinics  and  in  papers  that  he 


Fig.    31S. — One   style   of   Robinson's   .022   alignment   wire. 

gave  before  various  societies.    He  described  the  various  forms  of  appli- 
ances that  can  be  used  for  the  bodily  movement  of  teeth,  as  follows : 

"The  appliance  was  first  made  with  short,  split,  round  tubing  soldered 
to  the  labial  surfaces  of  the  incisor  bands  near  the  gingival  line.  The 
arch  made  of  .022  inch  wire  was  threaded  at  its  ends,  which  were  placed 
in  tubes  on  the  molar  bands.  The  arch  wire  was  engaged  in  the  short 
split  tubes,  and  at  the  points  where  it  emerged,  was  bent  sharply  to- 
ward the  incisal  edge.  It  was  allowed  to  extend  nearly  to  the  cutting 
edge,  and  was  then  bent  at  right  angles  and  passed  to  the  next  tooth, 
when  it  was  bent  at  right  angles  again  toward  the  gingival  line.  When 
it  reached  the  line  of  the  split  tubing,  it  was  bent  again  at  right  angles 
and  passed  through  the  next  tubing  and  so  on  for  each  tooth  (Fig.  315). 
By  proper  bending  of  the  wire,  pressure  could  be  brought  to  bear  on 
the  incisal  ends  of  the  teeth  in  the  lingual  direction,  and  at  the  same 


*Robinson,    R.    D. :      A    System   of   Positive   and    Painless    Tooth    Movement.      International 
Journal   of   Orthodontia,   October,   1915,  vol.   i,  p.   397. 


REGULATING   APPLIANCES  239 

time  it  would  pull  labially  011  the  gingival  portion  of  the  tooth.  In  this 
way  the  apices  of  the  roots  were  moved  labially,  and  the  incisal  ends 
lingually.  The  appliance  as  described,  did  very  good  work  in  certain 
instances,  but  its  usefulness  was  restricted  to  a  very  small  percentage 
of  cases.  The  things  of  greatest  interest  learned  were  the  length  of 
time  such  an  appliance  would  continue  its  pressure,  and  the  absence  of 
all  soreness.  After  this,  came  the  thought  that  better  control  could  be 
secured  if  the  rotation  of  the  arch  wire  in  the  tubing  could  be  prevented. 
To  this  end  square  split  tubing  was  secured,  and  a  square  wire  used, 
but  a  new  difficulty  immediately  arose.  When  the  wire  was  made  into 
loops,  it  was  found  that  no  two  loops  had  the  same  resistance,  for  a 
square  wire  bent  in  the  direction  of  one  side  will  not  have  the  same 


0    % 


kjH 


I  I 


Fig.  316. — Robinson's  blocks  and  seals  for  use  with  the  .022  alignment  wire. 

resistance  as  though  it  is  bent  in  the  direction  of  a  corner,  and  all  the 
different  angles  between  the  flat  side  and  the  corner  give  different  re- 
sults. A  triangular  wire  was  then  tried,  then  a  flat  wire  with  a  groove 
on  one  side  to  provide  means  for  locking  into  a  suitable  form  milled  from 
solid  metal  and  soldered  to  the  tooth  bands,  but  they  all  presented  diffi- 
culties. Then  came  the  idea  of  squaring  a  round  wire  just  at  the  points 
where  it  was  to  be  locked  to  the  bands.  When  a  wire  small  enough  to 
give  just  the  right  delicate  resilience  required  for  the  work  was  squared, 
the  squared  portion  was  too  small  to  handle,  and  when  it  was  made  large 
enough  to  handle,  it  was  too  stiff  to  give  the  results  desired.  After  a 
period  of  study,  came  the  idea  of  using  hollow  square  blocks  soldered 
on  the  arch  wire  at  the  places  where  the  attachments  were  to  be  made 
(Fig.  316).     That  was  the  first  real  step  in  developing  the  present  ap- 


240 


PRACTICAL    ORTHODONTIA 


pliance.  The  ability  to  lock  the  arch  wire  itself  into  the  seats  without 
soldering  on  attachments  was  at  first  held  by  the  essayist  to  be  a  ne- 
cessity, but  after  once  preparing  an  arch  in  this  way,  it  developed  that 
the  technique  is  so  simple  as  to  bother  no  one.  The  possibility  of  making 
an  error  in  alignment  in  soldering  the  block  to  the  arch  is  practically 
nil,  and  the  advantage  gained  is  so  great  that  there  can  be  no  question 


Fig.    317.  —  Robinson's   appliance   adjusted    to    upper   arch. 


as 


/■ 


o 


UN 


Fig.    318. — Robinson's    interlocking    slat. 


that  the  use  of  the  round  wire  and  the  soldered  blocks  will  be  accepted 
as  more  desirable  than  the  use  of  the  angular  wire.  Iridio-platinum 
seats  into  which  the  blocks  accurately  fitted,  were  constructed  and  sol- 
dered to  the  tooth  bands.  When  the  blocks  were  soldered  to  the  arch 
wire  and  locked  into  the  seats  by  bending  their  edges,  the  attachment 
between  the  arch  wire  and  tooth  was  rigid  (Fig.  317).     The  appliance 


REGULATING   APPLIANCES  241 

was  first  published  in  this  form,  and  much  good  work  was  done  with  it 
as  it  was  then  used,  but  a  serious  fault  developed.  When  the  seat  was 
made  thin  enough  to  bend  over  and  lock  the  block  in  place,  it  was  so 
frail  that  it  often  became  loose  under  continued  pressure  and  the  stress 
of  mastication,  allowing  the  block  and  arch  wire  to  slip,  and  thus  the 
force  was  not  applied  as  it  should  have  been. 

"The  attachment  between  the  tooth  and  the  arch  was  then  made  by 
an  interlocking  seat  (Fig.  318-a)  and  block  (Fig.  318-6),  the  former 
being  soldered  to  the  tooth  band,  and  the  latter  to  the  arch  wire.  The 
seat  consists  of  a  flat  oblong  base  and  two  flat  parallel  walls  rising  at 
right  angles  to  the  base.  The  walls  are  rounded  at  the  top,  and  each  is 
pierced  near  the  top  with  a  small  hole,  the  two  holes  being  in  alignment. 
The  seat  is  made  of  platinum-gold  and  is  .022  inch  thick.  The  distance 
between  the  walls  or  across  the  base  of  the  seat  is  .040  inch. 

"The  block  is  of  platinum-gold,  but  harder  than  the  seat,  and  is  .040 
inch  thick  and  shaped  to  fit  inside  the  walls  of  the  seat  above  described, 
except  that  it  is  .005  inch  greater  in  elevation  than  the  side  walls  of  the 
seat,  which  provides  means  for  its  being  forced  into  the  seat,  with  a 
pair  of  pliers,  when  there  is  stress  on  the  arch  wire  to  which  it  is  sol- 
dered. The  block  (Fig.  318-6)  is  pierced  by  two  holes,  the  larger  runs 
longitudinally  and  its  bore  is  equal  to  the  diameter  of  the  arch  wire  used, 
or  .020  inch.  The  smaller  hole  is  through  the  transverse  diameter  of  the 
block  near  the  top  and  is  in  the  exact  place  to  be  brought  into  alignment 
with  the  two  holes  in  the  seat  walls  when  the  block  is  forced  into  place 
in  the  seat.  The  block  is  locked  into  the  seat  by  placing  a  delicate  pin 
through  the  seat  walls  and  the  block  (Fig.  318-cZ).  When  so  locked,  no 
play  is  possible.  The  two  parts  are  made  to  fit  to  the  minutest  fraction 
of  an  inch,  and  as  they  have  three  flat  walls  in  apposition,  and  are  locked 
firmly  together,  they  do  not  permit  of  any  play  whatever.  The  molar 
and  anterior  attachments  are  alike,  except  that  the  molars  are  the 
longer  (Fig.  318-c.) 

"The  technique  of  construction  is  very  simple.  The  tooth  bands  are 
first  constructed,  and  to  their  labial  surfaces  are  soldered  the  seats  (Fig. 
319).  No  necessity  exists  for  getting  them  into  alignment  with  each 
other,  or  of  getting  them  at  exactly  right  angles  to  the  long  axes  of  the 
teeth.  If  they  be  placed  somewhere  nearly  at  right  angles  it  will  be  suffi- 
cient. After  the  bands  with  the  seats  attached  have  been  cemented  to  the 
teeth,  the  arch  wire  is  prepared  as  follows :  A  piece  of  arch  wire  is  se- 
lected and  enough  blocks  to  correspond  with  the  number  of  tooth  bands 
are  threaded  on  the  wire ;  a  molar  block  being  first  and  last  with  the 
anterior  blocks  between.    One  of  the  molar  blocks  is  now  soldered  to  the 


242  PRACTICAL    ORTHODONTIA 

wire.  The  block  is  next  introduced  into  the  seal  in  the  mouth  and  the 
arch  wire  is  bent  in  such  a  way  as  to  bring  it  to  lie  through  the  next 
seat.  If  there  is  to  be  any  change  made  in  the  relative  position  of  the 
molar  and  the  first  tooth  to  be  engaged,  anterior  to  it,  a  loop  should 
be  made  in  the  wire  in  such  a  position  that  it  will  lie  near,  without 
touching,  the  gum,  and  then  bring  the  wire  to  lie  through  the  next  seat. 
When  this  has  been  done,  bring  forward  the  next  block  on  the  wire  until 
it  is  approximately  in  the  proper  place  to  go  into  the  seat.  Next,  with 
a  pair  of  crimping  pliers  having  a  delicate  projection  in  one  beak,  crimp 
the  block  on  the  wire;  now  the  block  may  be  forced  into  the  seat  and 
if  not  in  its  proper  place  on  the  wire,  it  can  be  forced  into  place  by 
grasping  the  ends  of  the  seat  and  block  in  a  pair  of  pliers  and  bringing 
force  to  bear.  As  they  are  exactly  the  same  length,  the  block  must  go 
to  its  proper  place.     The  arch  wire  is  now  removed  from  the  mouth  and 


^■L,   ^  ^jL-^~ 


Fig.   319. — Showing   construction   of   Robinson's   appliance. 

the  block  soldered,  there  being  little  danger  of  displacing  the  block  on 
the  wire  because  after  crimping  the  block,  force  must  be  used  to  change 
its  position  on  the  wire.  Each  block  is,  in  its  turn,  brought  to  its  proper 
place  and  soldered  in  a  like  manner,  loops  being  formed  wherever  neces- 
sary. After  the  last  block  has  been  soldered,  any  remaining  portion  of 
the  wire  is  cut  off.  It  will  nowr  be  found  that  when  the  arch  is  placed 
in  position  each  block  will  lie  passively  in  its  seat  (Fig.  320).  When 
the  work  required  of  the  arch  wire  has  been  determined,  it  is  bent  into 
the  necessary  form  and  is  then  replaced  in  the  mouth  and  each  block 
is  forced  into  its  corresponding  seat  and  locked  there." 

The  bodily  movement  of  teeth  by  the  use  of  a  seat  and  flat  arch  has 
been  described  by  Angle  under  the  trade  name  of  the  "ribbon  arch". 
It  has  features  very  similar  to  Kobinson's  appliances  in  that  it  makes 
use  of  a  seat  that  is  termed  a  bracket,  an  enlarged  view  of  which 
is  shown  in  Fig.  321.  The  ribbon  arch  fits  into  the  bracket,  as  shown 
in  Fig.  322.     A  small  hole  in  the  bracket  admits  of  the  passage  of  a 


REGULATING    APPLIANCES 


243 


small  pin,  which  locks  the  arch  in  place.  The  pin  is  made  with  a  small 
head  that  engages  the  ribbon  arch  and  does  not  pass  through  the  arch 
at  all.  The  bracket  is  made  on  the  band,  and  the  band  is  fitted  to  the 
teeth  by  pinching  the  strip  of  band  material  that  carries  the  bracket 
around  the  tooth,  and  then  it  is  soldered.  It  is  needless  to  say  that  the 
seam  of  the  band  is  always  made  on  the  lingual  side.     Fig.  323  shows 


Fig.   320. — Robinson's  alignment   wire   with  blocks  in   seats. 

bow  the  appliance  appears  when  adjusted  in  the  mouth.  In  the  correc- 
tion of  torsiversion,  the  appliance  is  employed  as  shown  in  Fig.  324.  The 
ribbon  arch  is  a  one-piece  arch,  the  ends  of  which  are  flattened  and  fit 
into  curved  tubes  on  the  molars'  bands,  as  shown  in  Fig.  325.  This 
gives  a  greater  degree  of  stability  and  prevents  the  alignment  wire  or 
ribbon  arch  from  turning  in  the  tube.  The  buccal  tube  is  also  curved  to 
follow  the  convexity  of  the  buccal  surface  of  the  molar,  which  places 
the  distal  end  of  the  tube  out  of  the  way  of  the  cheek  much  better  than 


Fig.    321. — Angle's    bracket    band. 
(Courtesy    of    S.    S.    White.) 


Fig.    322. — Ribbon    arch    in    bracket    of    Angle 

band. 

(Courtesy    of    S.    S.    White.) 


does  a  straight  tube.  The  bracket  can  be  turned  toward  the  occlusal  or 
towards  the  gingival  part  of  the  tooth,  depending  upon  what  is  to  be 
clone  and  upon  how  the  appliance  is  to  be  used.  In  Fig.  325  the  appli- 
ance is  adjusted  in  a  case  of  distoclusion,  and  in  Fig.  326  in  a  case  of 
mrsioclusion. 

Flat  arches  with  flat  or  oval  tubes  for  the  bodily  movement  of  molars 
are  also  in  use,  one  stvle  of  which  is  shown  in  Fig.  327.    Another  style  of 


244 


PRACTICAL    ORTHODONTIA 


Fie     323— Angle's   ribbon    arch    adjusted   to    the   teeth.      Fig.   324.— Angle's   ribbon   arch   adjusted 
ng.    o&o.      ^ins  v-  to   correct   torsiversion. 


Fie     325— Ribbon    arch    and    brackets    adjusted       Fig.    326.— Ribbon    arch    and    brackets   adjusted 
for    the    treatment    of    distoclusion.  for    treatment    of    mesioclusion. 


Fig      327.— Julius     Aderer's     clamp     band     for        Fig.    328.— Brady's    clamp    band    for    anchorage 
bodily  movement  of  molars.  and   use   with    alignment   wires. 


REGULATING   APPLIANCES 


245 


molar  band  that  can  be  used  with  any  form  of  attachment,  either  for 
the  bodily  movement  of  teeth  or  otherwise,  has  been  designed  by  Brady, 
and  is  shown  in  Fig.  328. 

The  Lingual  Arch  Used  in  Connection  With  the  Labial  Arch 

The  type  of  appliance  that  possesses  many  advantages  over  the  ma- 
jority of  other  appliances  is  the  lingual  arch  or  wire  supplemented  with 
the  labial  arch  or  wire  for  use  in  some  kinds  of  cases.  The  use  of  the 
labial  and  lingual  arch  produces  the  bodily  movement  of  the  teeth,  and 
in  most  instances  this  movement  can  be  produced  without  the  use  of 
any  bands,  which  make  the  appliance  much  less  conspicuous  than  it 
would  be  otherwise.     There  are  various  combinations  of  the  labial  and 


Fig.    329. — Early    form    of   labial    and    lingual    arch.      (Lourie.) 


lingual  appliances,  one  of  the  earliest  forms  being  that  shown  in  Fig. 
329.  Bands  are  placed  on  the  first  molars  and  the  lingual  arch  is  fitted 
to  the  lingual  surfaces  of  the  teeth.  In  a  great  many  cases  the  lingual 
arch  is  not  fitted  at  the  gingival  border  of  the  teeth  as  shown  in  this 
figure.  The  lingual  arch  exerts  an  outward  pressure  on  the  teeth  at 
the  gingival  portion.  On  the  buccal  surface  of  the  bands  are  soldered 
molar  tubes,  which  receive  the  labial  appliance,  as  shown  in  Fig.  330. 
This  labial  wire  carries  extension  spurs,  which  rest  against  the  labial 
surfaces  of  the  incisors  at  such  points  as  it  is  desired  to  bring  pressure. 
If  it  is  desired  to  continue  wearing  the  labial  wire  at  night  as  a  retain- 
ing appliance,  it  can  be  removed  in  the  daytime  and  placed  on  a  model- 
ing compound  form,  as  shown  in  Fig.  331.  As  long  as  the  labial  wire 
fits  the  form  accurately,  it  will  exert  the  proper  force  on  the  teeth  when 


246 


PRACTICAL    ORTHODONTIA 


it  is  replaced.     Should  the  labial  wire  become  bent,  the  patient  is  in- 
structed to  have  it  readjusted  by  the  orthodontist. 

The  combination  of  the  lingual  arch  with  the  labial  arch  has  many 
advantages  in  the  bodily  movement  of  teeth.    Fig.  332  shows  the  adjust- 


Fig.  330. — Front  view  of  labial  arch  in  combination  with  lingual.      (Lourie.) 


Fig.    331. — Modeling    compound     form     to    maintain    shape    of    labial    arch    when     not    on    teeth. 

(Lourie.) 


Fig.    332. — Lingual    arch    adjusted    with    buccal    tubes    on    molar    bands    to    receive    labial    arch. 

(Lourie.) 

ment  of  the  lingual  arch  with  bands  on  the  molars.  The  lingual  arch 
can  be  made  to  serve  the  purpose  of  expanding  the  dental  arch  and  at 
the  same  time  acting  as  an  anchorage,  while  the  labial  arch  is  producing 
the  bodily  movement  of  the  lateral  incisors  and  the  distal  movement 


REGULATING    APPLIANCES 


247 


\ 

^ 

5 

V 

\ 

s 

< 

Fig.    333. — Labial    wire    with    spring    extensions    for    use        Fig.    334. — Labial    wire    with    exten- 
with    lingual   arch.      (Lourie. )  sions    to    canines.       (Lourie.) 


Fig.    335. — Labial   and   lingual   arch   in   combination.      (Lourie.) 


Fig.     336. — Labial    and    lingual    arch     in    combination     showing    spring    extensions     for    canines. 

(Lourie.) 


of  the  canines,  as  well  as  the  depression  and  rotation  of  the  canine. 
The  molar  hands  carry  buccal  tubes,  to  which  is  fitted  the  labial  arch, 
shown  in  Fig.  333.  Bands  are  placed  on  the  lateral  incisors,  which 
carry  small  perpendicular  tubes  of  22-gauge  on  the  inside.  At  the 
proper  point  on  the  labial  arch,  which  has  been  fitted  above  the  gingival 


248 


PRACTICAL    ORTHODONTIA 


margin  of  the  teeth  to  make  it  less  conspicuous,  are  soldered  22-gauge 
spurs  of  spring  gold,  the  ends  of  which  are  bent  so  as  to  pass  into  the 
tube  from  the  occlusal  edge.  This  gives  a  greater  length  of  spur  and 
thereby  increases  its  elasticity,  and  the  bent  occlusal  end  enables  the 
tooth  to  be  rotated  by  bending  the  horizontal  part  of  the  bend.  The  ex- 
tension springs  soldered  to  the  labial  arch  just  in  front  of  the  screw  on 
the  labial  arch  have  their  anterior  ends  bent  at  right  angles,  which  are 
received  into  tubes  on  bands  that  have  been  placed  on  the  canines.     A 


Fig.    337. — Labial    wire    applied    gingivally    to    avoid    conspicuousness.       (Lourie.) 


Fig.    338. — Labial   wire   with   spring   extensions.      (Lourie.) 


side  view  of  the  appliance  is  shown  in  Fig.  334.  The  labial  arch  is  fas- 
tened in  position  by  means  of  a  traction  cable  that  is  tied  around  the 
distal  end  of  the  tube  and  in  front  of  the  nut.  Should  the  appliance 
exert  enough  force  to  make  the  teeth  sore,  instruction  is  given  to  cut 
the  string  and  remove  the  appliance. 

Another  form  of  the  lingual  and  labial  arch  in  combination  is  shown 
in  Figs.  335  and  336.  Spurs  have  been  soldered  to  the  lingual  arch  to 
engage  the  gingival  part  of  the  upper  lateral  incisors,  thereby  exerting 


REGULATING    APPLIANCES 


249 


Fig.  339. 


Fig.  340. 


250 


PRACTICAL    ORTHODONTIA 


force  nearer  the  neck  of  the  tooth ;  and  they  can  also  be  made  to  exert 
a  downward  pressure  if  the  tooth  is  in  infra-occlusion. 

A  more  recent  adoption  of  the  combination  of  the  labial  arch  with 
the  lingual  is  seen  in  Figs.  337  and  338.  Fig.  337  shows  the  bands  on  the 
first  molars  to  which  the  lingual  arch  has  been  soldered.  The  lingual 
arch  is  placed  gingivally  to  the  free  margin  of  the  gum  and  lies  far 
enough  toward  the  apical  portion  of  the  teeth  so  that  there  is  no  chance 
that  the  lingual  wire  will  hold  food  against  the  tissue.  Spur  extensions 
are  soldered  at  suitable  points  on  the  lingual  wire  to  exert  pressure  on 
the  desired  teeth.  These  spurs  are  so  bent  that  they  will  not  impinge  on 
the  gum  tissue  and  will  still  exert  force  against  the  necks  of  the  teeth. 
By  pinching  these  spurs  between  the  beaks  of  the  wire  stretchers  they 
can  be  lengthened,  and  force  can  be  exerted  upon  the  individual  teeth 
without  disturbing  any  of  the  other  teeth.  Tubes  are  soldered  on  the 
buccal  surfaces  of  the  molar  bands  for  the  purpose  of  carrying  the  labial 


Fig.   342. 


arch.  This  arch  is  made  from  17-gauge  iridio-platinum  or  gold  and 
platinum  to  which  is  soldered  22-gauge  elastic  gold  extension  spurs  for 
the  purpose  of  exerting  force  on  the  cutting  edge  of  the  incisors  and  pro- 
ducing a  bodily  tooth  movement. 

Fig.  338  shows  the  high  labial  arch  with  spring  extension  for  the  pur- 
pose of  exerting  a  lingual  pressure  on  the  anterior  teeth.  The  high 
labial  arch  can  also  be  used  with  the  recurved  or  J  extension  as  shown 
in  Fig.  333.  This  form  of  extension  is  employed  for  the  correction  of 
torsiversion  or  for  the  bodily  movement  of  the  tooth  or  for  both  forms 
of  tooth  movement.  Fig.  339  shows  the  high  labial  arch  with  recurved 
extensions  which  are  fitted  into  perpendicular  tubes  soldered  on  the  band 
fitted  to  the  lateral  incisors.  By  adjusting  the  position  of  the  recurved 
portion  of  the  J  extension  which  goes  into  the  perpendicular  tube,  it 
is  possible  to  get  any  tooth  movement  desired.    Fig.  340  shows  how  in- 


REGULATING    APPLIANCES 


251 


conspicuous  the  entire  appliance  is  when  the  lip  is  in  position.  The 
high  labial  arch  when  used  without  the  lingual  arch  also  provides  an 
excellent  appliance  for  the  expansion  of  the  arch  in  the  molar  and  pre- 
molar region,  either  when  a  bodily  movement  of  the  molars  is  required  or 
when  only  a  movement  of  the  crown  is  desired.  Fig.  341  shows  the 
construction  of  a  high  labial  arch  on  a  typodont,  for  the  purpose  of  ex- 
pansion in  the  molar  and  premolar  region.  On  the  molar  is  a  round 
buccal  tube  which  is  the  same  gauge  as  the  labial  alignment  wire,  17-  or 
18-gauge  being  the  best  size  to  use.  A  band  is  made  for  the  first  pre- 
molar Avhich  has  soldered  to  it  a  short  tube  of  22-gauge.  The  tube  on 
the  premolar  band  must  be  parallel  with  the  tube  on  the  molar  band 
occluso-gingivally.  The  labial  arch  is  fitted  as  shown  in  Fig.  341.  If  it 
is  desired  to  increase  the  expansion  in  the  molar  region,  the  portion 
of  the  labial  wire  that  goes  into  the  buccal  tubes  is  moved  buccally  by 
bending  the  perpendicular  part  of  labial  wire  buccally.     This  places 


Fig.  344. 


a  buccal  expansion  on  the  molars  without  any  tendency  to  rotate  the 
distal  portion  of  the  molar  buccal  as  so  often  happens  when  expansion 
is  produced  by  increasing  the  spring  in  the  old  style  labial  alignment 
wire. 

Soldered  to  the  labial  alignment  wire  in  the  premolar  region  just  an- 
terior to  a  point  corresponding  to  the  mesial  end  of  the  tube  on  the  pre- 
molar band  is  a  22-gauge  spring  extension,  the  occlusion  portion  of 
which  is  bent  into  an  L  with  the  parallel  portion  of  the  end  pointing 
distally.  This  spring  extension  is  for  the  purpose  of  expansion  of  the 
premolars  and  provides  the  necessary  force  without  changing  the  shape 
of  the  labial  wire.  In  order  to  move  the  second  premolar  and  canine 
buccally  without  any  extra  attachment  a  lingual  spur  is  soldered  to  the 
premolar  band  to  engage  the  canine  and  second  premolar.  These  two 
attachments  are  all  that  is  needed  to  control  the  expansion  of  the  lateral 


252 


PRACTICAL    ORTHODONTIA 


halves  of  the  arches,  and  provides  a  secure  attachment  and  one  easily 
adjusted.  Fig-.  842  shows  the  occlusal  view  of  the  appliance.  In  some 
cases  it  is  desirable  to  place  the  band  on  the  canines  instead  of  on  the 
premolars.  The  lingual  extension  soldered  on  the  canine  band  can  be 
made  to  engage  the  lateral  incisor  and  with  a  lingual  extension  on  the 
molar  band  we  have  control  of  all  of  the  teeth  except  the  central  inci- 
sors with  but  two  attachments  on  the  labial  wire.  No  ligatures  are 
used  and  the  attachments  are  far  enough  apart  so  as  to  allow  individual 
tooth  movement  and  adjustment.  Fig.  343  shows  the  buccal  view  of 
the  appliance  and  Fig.  344  the  occlusal  view.  In  using  the  lingual  arch 
in  combination  with  the  high  labial  arch  it  must  be  remembered  that  the 
lingual  arch  can  be  used  to  stabilize  the  anchor  teeth,  in  which  case  all 
of  the  force  to  correct  the  malposed  teeth  is  derived  from  the  labial 


Fig.    345. — View   of   labial   wire   in  use   showing   inconspicuousness.      (Lourie.) 


arch  or  the  lingual  arch  can  be  used  to  stabilize  the  molar  and  also  used 
as  an  appliance  for  expansion  in  the  premolar  and  canine  region.  In 
the  latter  form  the  labial  arch  and  finger  springs  exert  force  on  the 
anterior  teeth  and  are  used  in  this  manner  in  distoclusion  with  pro- 
truding anterior  maxillary  teeth. 

The  combination  of  the  labial  and  lingual  arches  makes  an  appliance 
that  renders  any  form  of  tooth  movement  possible  and  one  that  is  less 
conspicuous  than  any  other  type  of  appliance  that  is  capable  of  pro- 
ducing as  wide  a  range  of  movement.  Fig.  345  shows  that  the  extension 
spurs  are  the  only  part  of  the  appliance  that  is  visible.  Other  uses  of 
the  lingual  arch  with  its  combinations  will  be  shown  in  the  treatment 
of  cases. 


CHAPTER  VI 
REMOVABLE  REGULATING  APPLIANCES 

Regulating  appliances  are  mechanical  devices  for  exerting  force 
upon  malposed  teeth  for  the  purpose  of  creating  cell  activity  and 
thereby  causing  the  teeth  to  assume  a  proper  position  in  the  line  of 
occlusion.  These  appliances  are  divided  into  fixed  and  removable. 
The  fixed  appliance  has  been  described  in  a  previous  chapter  of  this 
book.  The  removable  appliances  will  be  considered  here  because  they 
possess  a  great  many  advantages  that  are  not  possessed  by  the  fixed 
appliances  and  embody  mechanical  principles  that  should  be  under- 
stood by  all  who  are  interested  in  the  practice  of  orthodontia. 

The  early  types  of  removable  regulating  appliances  were  neces- 
sarily crude,  although  they  possessed  certain  features  which  recom- 
mended them  for  use  in  the  treatment  of  malocclusion.  The  very 
early  appliance  embodied  some  form  of  spring  force  which  exerted  a 
mild  constant,  painless  pressure,  but  the  purpose  of  this  pressure  was 
often  defeated  by  the  fact  that  the  appliance  was  very  unstable  and 
very  difficult  to  keep  in  position.  It  is  through  the  work  of  Victor  H. 
Jackson  that  removable  regulating  appliances  have  been  brought  up 
to  their  present  standard.  "We  can  now  say  that  it  is  practically  pos- 
sible to  treat  any  type  of  malocclusion  with  the  removable  regulating 
appliance  that  can  be  treated  with  a  fixed  appliance. 

A  number  of  varieties  of  malocclusion  can  be  more  successfully  and 
more  easily  treated  from  the  patient's  standpoint  with  the  removable 
appliance  than  if  treated  with  some  of  the  fixed  forms  of  appliances 
which  are  on  the  market. 

The  early  type  of  removable  regulating  appliance  consisted  of  some 
form  of  a  plate,  force  being  exerted  by  means  of  a  spring.  The  Coffin 
split  spring  plate  which  is  shown  in  Fig.  346  was  this  type  of  appli- 
ance and  consisted  of  a  split  vulcanite  plate  covering  the  palate, 
touching  only  the  lingual  surfaces  of  the  teeth  and  relying  upon  the 
lingual  surfaces  for  retention.  It  has  the  double  loop  spring  of  18- 
gauge  steel  or  piano  wire  which,  when  the  plate  was  removed  from 
the  mouth,  could  be  bent  buccally,  causing  a  spring  force  for  the 
expansion  of  the  arch  when  the  plate  was  snapped  back  in  position. 
This  plate  was  very  satisfactory  in  accomplishing  the  expansion  of 

253 


2f>4  PRACTICAL    ORTHODONTIA 

the  upper  dental  arch  but  was  not  so  satisfactory  if  individual  tooth 
movement  Avas  required.  The  plate  also  possessed  very  insecure 
anchorage  and  to  overcome  this  insecure  attachment  Jackson's  earli- 
est appliances  consisted  of  the  addition  of  wire  clasps  made  to  cross 
the  occlusal  surface  of  the  interproximal  occlusal  groove  and  fitted  to 
the  bucco-cervical  border,  thereby  giving  a  greater  resistance  and 
attachment  to  the  removable  appliance  than  vas  obtained  with  the 
plain  vulcanite  plate. 

Fig.  347-A  shows  the  construction  of  a  plate  with  encircling  clasps 
around  the  molars,  and  Fig.  347-B  shows  the  same  construction  of  the 
plate  with  clasps  encircling  both  the  molars  and  premolars.  The  use 
of  these  clasps  tended  to  eliminate  the  bulky  portion  of  the  plate  over 
the  occlusal  surface  of  the  teeth  and  rendered  the  appliance  much 
more  cleanly  and  greatly  increased  its  stability.  After  the  clasp  was 
employed  for  the  use  of  the  vulcanite  plate,  it  was  then  used  with  an 


Fig.    346.— Type    of    Coffin's    split    spring    plate. 

all-metal  device  and  the  clasp  so  constructed  as  to  be  connected  across 
the  palate  with  wires  from  which  springs  Avere  to  be  extended  the 
same  as  in  the  vulcanite  (Fig.  348). 

The  original  design  of  the  Jackson  all-metal  removable  appliances 
Avas  limited  to  various  tooth  movements  bul  the  great  range  of  these 
designs  soon  made  it  possible  for  a  system  to  be  perfected,  governed 
by  definite  principles,  and  Limited  only  by  the  ingenuity  of  the  de- 
signer, for  the  correction  of  all  <-l;isses  of  irregularities. 

The  Jackson  system  of  removable  appliances  reached  a  stage  of 
perfection  between  IS!)!)  and  1900,  which  resulted  in  their  taking  the 
lead  among  removable  appliances.  Saving  mastered  the  technique  of 
these  appliances,  Jackson  obtained  the  most  beautiful  results,  and 
most  operators,  Avho  realize  the  superior  qualities  of  the  spring  force 
and  elimination  of  the  ninny  objectionable  features  of  the  fixed  type, 


REMOVABLE    REGULATING    APPLIAN(  ES 


255 


have  adopted  the  Jackson  system.  One  great  drawback  in  the  use 
of  removable  appliances  has  been  the  impossibility  of  securing  the 
cooperation  of  some  patients.  The  fact  that  the  removable  appliance 
••an  be  taken  out  of  the  mouth  and  the  teeth  cleansed  has  also  been  a 


l:ig.    .i-t". — A    shows   partially    encircling   clasps   around    the   molars,   and   B   shows   completely   en- 
circling clasps  around   the   first    bicuspids  and   first    molars  in  a  split   spring  plate.      (Eby.) 


Fig.   348. — A  and  B  show  all-metal   device  with  clasps  so   constructed  as  to  be  connected  across 
the   palate    with    wires,    from    which    springs   are    extended.      Early    forms    of    Jackson's    removable 

appliances.       (Eby.) 

disadvantage  in  the  months  of  those  patients  who  insist  upon  taking 
the  appliance  out  and  therefore  interfering  with  the  working  of  the 
appliance.  However,  these  disadvantages  have  been  gradually  elim- 
inated and  Jackson  has  designed  these  modern  appliances  so  that  it 
is  easy  for  the  operator  to  remove  them,  but  practically  impossible 


256 


PRACTICAL   ORTHODONTIA 


for  the  patient.  These  "removable-fixed"  appliances  designed  by 
Jackson  possess  many  advantages,  but  in  those  cases  where  the  coop- 
eration of  the  patient  can  be  secured,  it  is  still  possible  to  use  the 
simpler  form  of  the  Jackson  appliance. 

For  the  proper  construction  of  the  removable  appliance  it  is  neces- 
sary to  have  a  certain  number  of  instruments  for  the  purpose  of  bend- 
ing the  wire  and  making  the  part  of  the  appliance  so  that  it  will  do 
what  it  is  intended  to  do.  The  instruments  required  are  a  short, 
straight-ended  scissors,  a  combination  punch  and  contouring  pliers, 
straight  flat-ended  instrument  for  adaptation,  a  wire  cutter,  a  long- 
nosed  pair  of  pliers,  a  very  small-ended  round-nosed  pliers,  and  par- 


Fig.    349. — Instruments   used   in    technique.    (Eby.) 


allel  pliers.  These  instruments  are  shown  in  Fig.  349.  No  pliers  is 
better  adapted  to  the  contouring  of  plates  and  metal  for  the  lingual 
surfaces  of  the  anterior  teeth  than  the  S.  S.  W.  pliers,  No.  112.  All 
other  appliances  which  have  been  tried  either  undercontour  or  over- 
contour  and  crimp  the  strip,  which  will  interfere  with  the  metal  being- 
adapted  to  the  convex  surface  of  the  tooth.  The  round-nosed  pliers  is 
used  for  practically  all  wire  bending  and  should  be  very  small  at  the 
end  in  order  to  make  the  bending  more  accurate.  The  ends  of  these 
pliers  can  be  made  small  by  fastening  them  in  a  vise  with  the  jaws  of 
the  pliers  closed  and  with  a  strip  of  emery  cloth  uniformly  reduce 
the  exterior  diameter  of  the  point.  The  parallel  pliers  are  used  for  the 
bending  of  the  heavy  wire.     Side  cutters,  for  cutting  the  wire,  are 


REMOVABLE    REGULATING    APPLIANCES 


257 


indispensable.  Fig.  350  shows  a  soldering  equipment  which  consists 
of  a  brush  burner  and  a  one-pound  pair  of  soldering  coppers.  These 
soldering  irons  should  be  pure  copper  as  the  composition  metal  iron 
will  oxidize  very  rapidly,  will  pit,  and  will  not  control  block  tin  accu- 
rately. Irons  smaller  than  one  pound  to  the  pair,  that  is,  one-half 
pound  each,  burn  rapidly  and  do  not  hold  heat  long  enough,  and 
larger  irons  are  more  cumbersome  and  clumsy  and  require  too  long  a 
time  to  heat.  The  soldering  flux  is  a  saturated  solution  of  zinc 
chloride  and  should  be  applied  abundantly  with  a  camel's-hair  brush. 


Fig.    350.  —  Soldering   equipment,    consisting   of    .1   lirush    burner   and   a    1-pound    pair    of   soldering 

coppers.      (  FJiv.  | 

This  solution  can  be  better  made  than  that  which  is  usually  bought,  by 
pouring  hydrochloric  acid  (C.  P.)  slowly  over  the  zinc  globules.  The 
zinc  should  remain  in  excess,  as  the  free  acid  will  attack  the  metals. 
This  solution  is  put  in  a  large  vessel  (Fig.  350)  in  order  that  the  iron 
may  be  kept  perfectly  tinned  by  emerging  the  point  after  each 
heating. 

The  first  material  to  be  mentioned  for  use  in  the  construction  of  the 
Jackson  appliance  is  Jackson's  partial  clasp  metal,  36-gauge  (Fig. 
351).  This  is  a  specially  prepared,  stiff  material,  not  to  be  annealed, 
which  responds  to  the  contouring  pliers,  but  is  so  resistant  to  bend- 


258 


PRACTICAL    ORTHODONTIA 


ing  that  it  will  not  yield  to  stress  during  insertion  and  removal 
of  the  appliance.  This  material  is  treated  on  one  side  to  cause  a 
tenacious  attachment  to  the  tin,  and  it  is  impossible  to  scale  off  the 
plates  when  made  of  this  special  metal.  All  substitutes,  such  as  low 
carat  gold,  copper,  platinoid,  nickel  silver,  or  brass  of  many  forms, 
cannot  be  used  with  as  great  success  as  can  this  metal.  This  metal 
possesses  a  gold  surface  for  contact  against  the  enamel. 

The  wire  used  in  making  the  Jackson  removable  appliance  is  an 
alloy  of  nickel  silver,  as  springy  as  possible,  and  also  bendable.  The 
gauges  required  are  Nos.  20  and  21  for  clasps,  18,  19  and  20  for  finger 


Fig.   351. — Materials  used  in  technique.      (Eby.) 

springs,  and  10,  11  and  12  for  connecting  body  wires.  This  material 
can  be  purchased  at  the  supply  houses.  The  solder  must  be  purest 
block  tin  (Fig.  351).  Manufactured  market  block  tin,  which  abounds 
in  arsenic  and  is  slightly  irritating,  and  the  best  tin  procurable,  is  the 
tin  used  in  making  an  alloy.  Half  and  half  solder  should  never  be 
used. 

In  the  construction  of  the  Jackson  removable  appliance,  it  is  neces- 
sary that  we  have  a  perfect  model  showing  all  the  anatomic  outlines 
of  the  parts.  These  models  should  be  made  from  plaster  impressions, 
as  it  is  necessary  that  all  the  surfaces  of  the  teeth,  including  the  lin- 


REMOVABLE   REGULATING   APPLIANCES  259 

gual  and  buccal  surfaces,  be  clearly  outlined.  The  models  should  be 
made  from  the  finest  grade  of  plaster  of  Paris.  When  the  very  hard 
compositions  of  modeling  materials  are  used,  or  if  the  plaster  of  Paris 
is  boiled  in  stearine  or  paraffin,  the  possibility  of  exercising  exact 
technique  is  lost. 

Models  should  not  only  be  made  of  plain  plaster,  but  should  be  used 
moist.  Wlien  the  numerous  parts  are  made  over  dry  plaster  surfaces 
they  have  to  be  removed,  set  aside,  and  assembled  when  all  parts  are 
finished.  By  this  plan  the  desired  accuracy  is  lost  because  the  pro- 
gressive process  of  building  one  part  upon  another,  from  the  first  to 
the  last,  and  if  the  parts  first  made  are  removed  it  is  impossible  to 
make  allowance  for  the  subsequent  parts  to  fit  over  them  accurately. 
If  the  model  plaster  is  moistened,  the  individual  parts  have  sufficient 
adherence  to  remain  in  position,  allowing  the  advanced  steps  to  be 
taken  with  accurate  calculation  of  size. 

As  soon  as  the  design  of  the  appliance  has  been  determined  the  next 
step  is  the  carving  of  the  cervical  border  of  the  posterior  teeth  selected 
to  bear  the  "partial  clasp"  lingually  and  the  "spring  clasp"  buccally. 
Jackson  has  always  emphasized  this  point,  for  the  security  of  the 
anchorage  depends  upon  the  use  of  the  cervical  constriction.  Along 
the  linguo-cervical  borders  of  all  posterior  teeth  which  are  to  carry 
"partial  clasps"  a  very  thin,  sharp-pointed  instrument  should  be 
drawn  to  make  a  narrow  groove  to  represent  the  natural  space  be- 
tween the  cervix  and  the  gingival  border  of  the  free  margin  of  the 
gum.  The  instrument  should  be  inserted  at  an  angle  of  approximately 
35  degrees  from  the  axis  of  the  tooth  to  carve  out  the  groove  anatom- 
ically correct  (Fig.  352).  The  bucco-cervical  border  of  teeth  to  bear 
spring  clasps  must  be  brought  out  clearly  by  trimming  away  the 
slightest  possible  amount  of  outline  of  the  margin  of  the  gum.  To  do 
this  the  instrument  should  approach  the  surface  at  right  angles  from 
the  axis  of  the  tooth  (Fig.  353).  The  surplus  left  between  this  line 
and  the  buccal  surface  can  be  carved  away,  thus  opening  a  distinct 
outline  of  the  bucco-cervical  border  to  which  the  clasp  is  fitted 
(Fig.  354). 

The  next  step  is  the  construction  of  partial  clasps.  Partial  clasps 
are  made  of  partial  clasp  gold,  a  material  especially  prepared  by  Jack- 
son and  mentioned  in  the  former  part  of  this  chapter.  The  success  of 
the  attachment  of  the  appliance  depends  greatly  upon  the  adaptation 
of  the  partial  clasp  to  the  lingual  surface  constriction  of  the  anchor 
teeth,  held  in  position  by  spring  clasps  buccally.     As  these  borders 


260 


PRACTICAL    ORTHODONTIA 


slide  over  the  lingual  surfaces  during  removal  and  insertion  they 
would  be  bent  outward  if  made  of  soft  material,  thus  causing  the 
apparatus  to  loosen.  The  strain  will  also  cause  a  weak  soldered  con- 
nect ion  to  loosen  so  that  the  "partial  clasp"  will  peel  off,  leaving  only 
a  soldered  surface  in  loose  contact  with  the  tooth.  For  these  two  prin- 
cipal reasons  this  material  has  no  substitute  and,  being  the  first  step 
in  the  construction,  failure  here  will  result  in  the  complete  failure  of 
the  appliance.  Partial  clasps  are  to  be  fitted  to  all  the  posterior  teeth 
engaged  in  the  arms  of  the  appliance  for  anchorage.  They  must  be 
fitted    with    perfect    accuracy,    well    into    the     cervical     constrictions, 


Fig.    352. — Carving  model   prior   to   fitting  partial   clasps.      (IJby.) 


slightly  beneath  the  free  margin  of  the  gums.  However,  they  must 
not  be  carried  far  enough  gingivally  to  interfere  with  the  fibers  of 
the  peridental  membrane  and  produce  irritation.  The  ends  of  the 
partial  clasps  should  extend  to  the  mesial  and  lingual  aspects  of  the 
lingual  surfaces  but  not  into  the  proximal  surfaces.  If  the  ends  pro- 
ject too  far  interproximal ly.  they  prevent  the  appliance  from  receding, 
wedge  the  teeth,  and  cause  painful  injury  to  the  interproximal  tissue. 
Partial  clasps  should  extend  towards  the  lingual  cusps  slightly  occlu- 
sally  to  the  point  of  greatest  convexity  on  the  lingual  surface  but  not 
far  enough  to  interfere  with  the  occlusion  (Fig.  355). 


REMOVABLE    REG! 'EATING    APPLIANCES 


261 


Fig.    353. — Carving   gingival   surface    of   model    prior   to    fitting   of   spring   clasps. 


Fig.  334. — Carving  buccal   surface  of  tooth  prior  to  fitting  spring  clasp.      (Eby.) 


262 


PRACTICAL    ORTHODONTIA 


The  treated  surface  of  the  metal  must  be  faced  outwards,  with  the 
pure  gold  surface  touching  the  model,  and  this  especially  treated  sur- 
face can  be  readily  distinguished  by  the  color  and  finish.  A  wider 
strip  should  always  be  cut  for  the  molars  than  for  the  premolars  in 


Fig. 


355. — Showing     construction     of     partial 
clasp.      (Eby.) 


Fig.     356. — Contouring     pliers     used     to 
contour   partial    clasp   metal.    (Eby.) 


Fig.   357. — Pressing  partial  clasp  into  place.      (FJjy.) 

curve  of  the  gingival  surface  to  any  desired  length.  After  trimming 
The  contouring  pliers  (Fig.  356)  will  conform  the  strips  to  the  double 
order  to  keep  the  occlusal  border  on  a  straight  line  mesio-distally. 
the  cervical  border  to  fit  perfectly,  the  partial  clasp  should  be  carried 


REMOVABLE   REGULATING   APPLIANCES  263 

to  place,  with  the  curve  of  the  plate  smaller  than  the  surface  curve 
of  the  lingual  of  the  tooth  and  it  then  can  be  enlarged  by  pressing  it 
into  position  where  it  will  remain  securely  (Fig.  357). 

Spring  clasps  are  divided  into  two  forms — full  and  partial.  The 
full  spring  clasp  entirely  circles  the  tooth,  crossing  from  the  lin- 
gual to  the  bucco-cervical  constriction  over  the  interproximo-occlusal 
groove,  with  both  ends  attached  in  the  solder.  This  design  is  typical 
of  the  removable  appliance.  The  partial  spring  clasp  partially  encir- 
cles the  tooth  only,  crosses  only  the  mesial  or  distal  interproximo- 
occlusal  groove,  traversing  the  bucco-cervical  constriction,  terminating 
in  the  opposite  proximal  side  whence  it  is  crossed  for  attachment  lin- 
gually.  This  clasp  is  used  both  in  the  fixed-removable  and  removable 
type.  Two  spring  clasps  are  employed  on  both  sides  of  the  arch  to 
secure  balance  of  attachment  and  are  usually  attached  on  the  most 
anterior  and  most  posterior  teeth  in  the  arms  of  the  appliance.  Spring 
clasps  are  made  of  21-gauge  or  22-gange  special  alloy  nickel  silver 
wire.  No.  21-gauge  is  generally  indicated  in  all  partial  spring  clasps 
and  also  in  the  full  spring  clasp  excepting  for  especially  large  teeth. 
The  wire  should  be  cut  into  two  and  three-inch  lengths  and  the  bend- 
ing begun  in  the  middle  to  permit  a  free  holding  for  bending  until  the 
clasp  is  complete.  The  clasp  Avire  should  first  be  bent  to  the  curve  of 
the  gum  scallop  on  the  buccal  surface  with  the  two  ends  pointing 
occlusally  to  the  proximal  side. 

After  this,  the  second  step  is  to  bend  this  bucco-cervical  portion  into 
a  second  curve,  the  curve  of  the  bucco-cervical  constriction,  mesio- 
distally.  For  this  it  is  necessary  to  use  the  brace  of  a  rubber  block  to 
control  the  bending  accurately  (Fig.  358). 

The  third  bend  requires  the  greatest  accuracy  because  it  forms  the 
angle  between  the  buccal  and  occlusal  surfaces.  If  this  bend  is  too 
high,  it  causes  the  occlusal  portion  to  interfere  in  occlusion.  If  it  is 
bent  too  low,  the  bucco-cervical  region  will  be  too  short  on  the  teeth 
to  reach  the  cervical  constriction.  The  operator  should  possess  a 
medium-length  left  thumb  nail  so  that  it  can  grasp  the  wire  accurately 
(Fig.  359),  bringing  off  the  wire  so  the  end  of  the  round-nose  plier 
can  pick  up  the  exact  point  by  running  down  over  the  surface  of  the 
thumb  nail  (Fig.  360).  It  is  far  better  to  continually  underbend,  try- 
ing to  position  frequently  and  in  this  way  make  continuous  progress. 
By  bending  too  far  the  work  will  be  undone,  started  over  again,  and 
usually  the  part  is  ruined  by  inaccuracy  and  breaking  by  the  crystal- 
lizing of  the  wire, 


264 


PRACTICAL    ORTHODONTIA 


In  making  full  spring  clasps,  the  mesial  and  distal  portions  should 
be  carried  across  the  occlusal  surface  together,  for  if  one  side  is  fin- 
ished first,  the  clasp  is  liable  to  -be  warped.  After  fitting  across  the 
occlusal  surfaces,  the  ends  are  bent  downward  to  be  curved  around 
midway  of  the  partial  clasps  for  soldering.     The  mesial  end  should  be 


Fig.    358. — Bending   clasp    wire    on    rubber   block.      (Eby.) 


Fig.   359. — Obtaining  measurement   of   occluso-gingival   portion   of  clasp.      (Eby.) 

bent  to  transverse  the  entire  length  of  the  partial  clasp  distally  and 
vice  versa,  so  as  to  gain  a  strong  "mechanical"  attachment  in  the 
solder.  If  these  ends  are  cut  short  they  will  pull  out  of  the  tin, 
which  is  cansed  by  mild  galvanic  erosion  which  gradually  makes  in- 
gress between  the  wire   and  the  tin,  loosening  the   adhesion  a  short 


REMOVABLE    REGULATING    APPLIANCES  265 

length  around  the  wire  at  the  point  of  entrance  into  the  tin  causing  a 
short  straight  end  to  pull  out. 

It  is  also  important  to  extend  the  end  of  the  spring  clasp  wires  to 
rest  against  all  portions  of  clasps  not  engaged  (Fig.  361).   If  this  is  not 


Fig.    360. — Bending   clasp   around    round-nosed    pliers.      (Eby.) 

done,  the  attraction  of  the  molten  tin  as  it  is  drawn  over  the  partial 
clasps  on  the  soldering  iron  is  liable  to  pull  them  oft'  or  displace  them 
slightly.  After  finishing  the  partial  clasp  and  the  spring  clasp,  the 
anchorage  or  "anus"  are  completed.     It  is  best  to  begin  to  unite  the 


Fig.    361. — Use    of    pins    to    hold    partial    clasps    in    position    while    soldering.       (Eby.) 

number  of  small  parts  at  this  junction,  reducing  to  one  unit  on  each 
side  the  five  or  ten  small  parts,  for  it  is  very  important  to  preserve 
them  accurately  as  they  are  liable  to  lie  displaced  during  the  advanced 
steps  if  not  united.     The  weight  of  the  soldering  iron  against  the  lin- 


26G 


PRACTICAL    OKTIIODONTI  \ 


glial  ends  of  the  clasp  is  liable  to  elevate  the  bucco-eervical  portion 
where  the  greatest  accuracy  is  required.  To  prevent  this,  pins  should 
be  inserted  to  hold  the  clasp  very  securely  in  place  (Fig.  361).  The 
thinnest  film  of  solder  possible  to  make  the  attachment  should  be  used 
to  keep  down  the  bulk  of  the  appliance  (Fig.  362). 

The  next  step  is  the  construction  of  the  "base  wires"  or  "body 
wires"  for  the  connection  of  the  anchor  arms  across  the  palate  in  the 
ripper  end  and  in  the  sublingual  region  of  the  lower.  The  body  wires 
are  made  of  12-gauge  for  average  cases,  although  the  gauge  should 
range  from  9  to  14,  varying  with  the  age,  extent  of  development  re- 
quired, and  the  control  of  bulk.  The  body  wires  should  be  made  into 
a  number  of  different  designs,  but  the  besl  plan  to  follow  is  to  use 
the  simplest  form  suited  for  the  needs  required.     The  simplest  form  of 


p[       j  j 

/   j 

■^ Hi 

H 

?  1 

^ 

■•L_y 

Fig.     362. — Partial    clasps    and     spring    clasps 
united    with    solder.      (F,by.) 


Fig.    363. — Body    wire    for    anterior    expansion 
(Fby.) 


upper  body  wire  is  made  for  premolar  and  anterior  expansion  only 
(Fig.  363).  This  form  is  made  by  bending  a  piece  of  wire  about  six 
inches  long  into  a  U-shape  to  fit  around  the  dome  of  the  palate  at  the 
desired  point  across  the  molar  region.  Care  must  be  taken,  in  de- 
termining the  points,  to  bend  the  ends  forward  from  the  points  of 
contact  againsl  the  molars.  If  these  angles  are  too  high,  they  will  in- 
terfere with  the  occlusion  and  impart  bulk  and  bad  finish.  The  meas- 
urements should  be  taken  with  a  thumb-nail  grasp,  as  before  described, 
and  should  be  low  enough  so  that  the  outer  curve  of  the  wire  will  only 
touch,  or,  failing  to  touch,  will  approximate  closely  the  linguo-cervical 
border  of  the  molar. 

In  all  heavy  wire  bending,  special   care  must  be  taken  to  calculate 
the  position  of  the   outer   curves,   and   to   do   this   the   wire  must   be 


KEMOVABLE   KEGULATING   APPLIANCES  267 

grasped  in  the  pliers  at  a  point,  the  diameter  of  the  wire  away  from 
the  desired  point  of  the  bend,  so  as  to  make  this  allowance  in  the 
height  of  the  curve.  The  palatal  part  of  the  wire  should  enter  the 
sides  about  midway  of  the  lingual  surface  of  the  distal  teeth  engaged 
in  the  appliance,  and  the  ends  should  always  extend  forward  or 
backward,  as  the  case  may  be  in  the  different  designs,  to  about  mid- 


Fig.   364. — Body  wire  for  premolar  and   molar        Fig.    365. — Body    wire    for    expansion    of    both 
expansion    on    one    side    only.       (Kby.)  sides    of    upper    arch.       (Fby.) 


Fig.   366. — Form  of  body  wire  used  in  premolar  and   molar   expansion.     Body  wire  attached    with 

soft   solder.      (Eby.) 

way  of  the  lingual  surface  of  the  tooth  at  the  opposite  end  of  the 
anchor  arms.  This  will  impart  a  round  finish  at  the  ends,  which  is 
lost  if  the  end  projects  beyond  the  point. 

It  is  absolutely  necessary  for  the  side  parts  of  the  body  wires  to  ex- 
tend the  full  length  of  the  anchor  arms  to  render  them  rigid.  Because 
the  linguo-cervical  borders  of  the  molars  are  higher  than  the  pre- 


268 


PRACTICAL    ORTHODONTIA 


molars,  it  will  be  found  that  as  the  side  of  the  body  wire  extends  for- 
ward, a  space  will  be  formed  between  the  wire  and  the  partial  clasp 
on  the  premolar.  It  is  in  this  space  that  the  ends  of  the  anterior  ex- 
tension must  be  fitted  and  soldered,  and  the  size  of  the  space  may  be 
determined  by  the  number  of  springs  to  be  used  (Fig.  363). 

Fig.  364  illustrates  the  body  wire  for  premolar  expansion  and  molar 
expansion  on  one  side  only.  Fig.  365  illustrates  a  body  wire  for 
bicuspid  and  molar  expansion  on  both  sides.  These  are  made  by  bend- 
ing the  wire  into  the  U-shape  on  the  curve  of  the  palate  at  the  pos- 
terior region,  and  then  the  forward  bends  are  made  to  be  looped  back 
parallel  around  the  jaws  of  a  round-nosed  pliers  so  that  the  end  will 
terminate  at  the  molar.     Care  must  be  taken  to  preserve  the  space  at 


Kig.    367. — Base    wire    being    bent    with    Case's 
bending   pliers.      (Eby.) 


Fig   368. — Case's    wire-bending 
pliers.       (IJby.) 


the  bicuspid  region  for  the  anterior  springs,  and  this  last  loop  must 
not  be  higher  than  the  cervical  zone  so  the  finished  appliance  will  not 
interfere  occlusally. 

The  form  of  body  wire  found  to  be  most  effective  for  the  premolar 
and  molar  expansion  on  both  sides  is  shown  in  Fig.  366.  This  design 
contains  less  material  than  the  one  shown  in  Fig.  365  and  responds 
to  lines  of  lateral  development  with  better  effect.  In  constructing 
this  style  of  body  wires,  the  wire  is  first  bent  into  a  U-shape  to  rest 
in  the  dome  anterio-posteriorly  with  the  ends  pointing  distally.  The 
ends  are  then  looped  over  the  jaw  of  the  round-nosed  pliers  and 
brought  forward,  observing  the  same  precautions  as  to  position  and 
terminating  midway  of  the  lingual  surface  of  the  teeth  at  the  anterior 


REMOVABLE    REGULATING    APPLIANCES 


269 


end  of  the  anchor  arms.  The  body  wires  must  not  touch  the  soft  tis- 
sues at  any  point.  After  construction,  they  may  he  held  to  position 
with  moldine,  and  should  lie  quickly  lacked  to  place  with  a  very  light 
solder  on  both  ends  and  both  sides  (Fig.  366).  The  finer  bending  of 
these  heavy  wires  (Fig.  367)  can  be  made  to  best  advantage  with  the 
plier  designed  by  Case  (Fig.  368).  Soldering  the  body  wire  to  posi- 
tion completes  the  body  and  arm  portions. 


Fig.    Zb9. — Showing    construction    of    finger    spring    to    body    wire.       (  l'.l.y.  i 


Fig.    370. — Soldering    finger    spring   to   body    wire.      (Eby.) 


270  PRACTICAL    ORTHODONTIA 

All  extensions  and  springs  from  these  parts  are  known  as  "finger 
springs"  or  "fingers."  Fingers  are  made  of  18-,  19-,  and  20-gange 
wire,  and  are  adjusted  usually  to  the  surface  of  the  teeth  opposite  the 
direction  of  motion.  Fingers  vary  in  design  with  every  individual 
case. 

Careful  comparison  of  a  given  irregularity  with  the  normal  and 
measurements  to  determine  the  extent  and  direction  of  the  usual  move- 
ment may  show  the  path  of  movements  towards  the  normal  to  be  such 
that  the  arch  may  be  corrected  in  segments,  and  the  study  of  other 
conditions  may  show  that  all  the  teeth  must  move  on  individual  paths. 
The  effectiveness  of  the  Jackson  method  is  its  great  adaptability  of 
design  to  meet  various  conditions  with  equal  advantage  and  facility. 

Fig.  369  shows  a  condition  caused  by  permanent  extraction  of  the 
left  deciduous  cuspid,  which,  by  breaking  the  proximal  continuity  of 
the  arch,  allowed  the  muscles  to  narrow  the  two  posterior  segments 
and  drift  the  incisors  lingually  from  the  right  canine  at  the  center  of 
the  rotary  axis.  The  molar  expanding  body  wire  is  indicated  for 
restoring  the  two  posterior  segments  to  normal  width. 

One  lingual  "finger"  bent  on  the  normal  curve  of  the  lingual  sur- 
faces should  be  attached  to  the  right  arm  of  the  appliance.  By  ren- 
dering this  finger  active  with  the  right  canine  at  the  rotary  center,  the 
path  of  movement  of  each  incisor  will  be  determined  by  the  radius 
of  the  spring  from  the  central  axis  of  the  point  of  contact  at  each 
tooth.  The  path  of  movement  of  the  left  lateral  will  be  outward  and 
to  the  right  on  a  greater  arc  than  that  of  the  left  central.  The  path 
of  movement  of  the  left  central  will  be  on  a  greater  arc  than  that  of 
the  right  central.  The  path  of  movement  of  the  right  central  will  be 
on  a  greater  arc  than  that  of  the  right  lateral.  By  the  pressure  of  this 
spring,  each  incisor  will  be  moved  along  a  different  path  toward  its 
normal  position,  restoring  normal  incisal  relations  and  concentrating 
the  space  gained  for  the  left  canine. 

The  appliance  is  shown  in  Fig.  370  prepared  for  the  finished  solder- 
ing on  the  right  side.  The  finger  is  held  in  position  with  moldine, 
and  the  spring  clasps  repinned  into  position  to  prevent  them  from 
slipping  buccally.  Zinc  chloride  is  now  applied  to  the  entire  side 
freely.  The  hot  soldering  iron  is  dipped  continually  in  the  flux  before 
soldering  to  keep  it  well  tinned  and  cleaned.  Globules  of  pure  block 
tin  are  carried  on  the  iron  and  flowed  well  down  into  the  crevices  be- 
tween the  clasps  and  the  body  wire.  Enough  solder  should  be  applied 
to  slightly  round  off  the  exposed  surface,  to  impart  a  smooth  finish. 

Fig.  371  shows  the  buccal  aspect  of  the  left  side  finished.    A  buccal 


REMOVABLE    REGULATING   APPLIANCES  271 

"finger"  has  been  extended  to  press  the  canine  into  alignment  after 
ample  space  is  made  for  it.  This  illustration  also  shows  how  the 
spring  clasp  has  been  shifted  to  the  second  premolar  and  second  molar 
on  this  side  to  prevent  the  need  of  two  wires  crossing  the  occlusion 
between  the  premolar  and  the  canine. 

Fig.  372  illustrates  the  exposed  aspect  of  a  soldered  appliance  ready 


Fig.    371. — Finger   spring   used    for    depressing    canine.      d'.l.y.) 


Fig.  372. — Appliance  completely  soldered.     (Eby.) 

for  removal  from  the  model  for  the  first  time  for  polishing.  It  also 
shows  the  laterals  collared  with  lugs,  soldered  to  the  lingual  surfaces 
beneath  which  the  "finger"  snaps  to  be  held  securely  in  position.  All 
of  the  posterior  teeth  are  anchored  against  the  labial  movement  of  the 
incisors.    The  incisors  and  right  posterior  teeth  are  anchored  against 


272  PRACTICAL    ORTHODONTIA 

the  left  posterior  teeth  (ten  anchor  teeth  against  four  teeth  to  be 
moved)  which  have  moved  lingual ly  more  on  the  right  side.  The  ex- 
posed surface  of  the  appliance  removed  from  the  model  is  shown  in 
Fig.  373. 

After  a  sufficient  amount  of  tin  is  added  to  the  side  of  the  arm,  it 
should  be  melted  along  the  full  length  at  one  time.    This  will  cause  it 


Fig.    373. — Appliance    removed    from   model.      (Eby.) 


Fig     374.— Cutting    out    solder    to    prevent    pressure    on    gingival    gum    tissue.       (Eby.) 

to  harden  in  a  uniform  smooth  surface  which  requires  only  a  few 
strokes  from  a  sand  paper  disc  to  prepare  for  the  lathe  polishing.  The 
lingual  side  of  an  appliance  requires  very  little  attention  in  polish- 
ing. Sharp  projections  of  the  partial  clasps  extending  too  far  inter- 
proximal^ should  be  cut  away.     When  the  solder  runs  around  the 


REMOVABLE   REGULATING    APPLIANCES  273 

ends  of  all  the  wires,  completely  enveloping  them,  it  is  east  against  a 
strip  of  plaster  representing  the  outline  of  the  free  margins  of  the 
gums.  If  this  solder  should  touch  the  soft  tissues,  a  slight  compres- 
sion will  he  established  as  the  appliance  settles.  This  pressure  will 
exclude  the  circulation  from  the  capillary  terminals  and  will  de- 
vitalize strips  of  tissue  which  will  resolve  into  a  dense,  white  mass. 
To  avoid  this,  the  palatal  side  of  the  tin  between  the  cervical  border 
of  the  partial  clasp  and  the  body  wire  should  be  cut  out  to  a  reason- 
able depth,  forming  a  smooth,  concave  surface  with  a  self-cleansing 
space  between  the  appliance  and  the  gum  (Fig.  374).  Cheat  care 
should  be  taken  in  this  step  not  to  injure  the  cervical  borders  of  the 
partial  clasps,  and  they  should  be  left  projecting  well  up  above  the 
tin  to  enter  the  cervical  constriction  at  the  gum  border.  Fig.  375  il- 
lustrates this,  showing  a  cross  section  cut  through  the  middle  of  the 
molar  clasp. 


Fig.    375. — Cross   section    of    base    wire    ami    partial    clas|p,    showing    gingival    extensions.       (Eby.) 

After  excluding  all  sharp  points  to  be  found  and  rounding  the  ends 
of  the  finger  springs,  appliances  are  polished  with  the  lathe.  A  felt 
wheel  should  be  used  and  a  stiff  mixture  of  pumice  to  the  exposed 
surface  of  the  tin.  which  will  make  the  tin  very  smooth.  The  lingual 
portion  of  the  tin  should  be  polished  with  bristle  brush  wheels  with 
ample   pumice. 

After  removing  all  tool  scrapings  and  pumice,  a  luster  can  be  im- 
parted by  washing  off  the  pumice,  drying  the  appliance  and  reapply- 
ing the  same  brush  wheel  with  which  the  pumice  was  used,  when  the 
moist  bristles  and  the  slight  amount  of  remaining  pumice  will  impart 
a  lasting  finish.  The  final  luster  can  also  be  made  by  prepared  chalk 
paste  on  a  camel 's-hair  wheel. 

The  construction  of  the  lower  removable  Jackson  appliance  is  very 
similar  to  the  construction  of  the  upper  appliance.  The  posterior, 
side  arm  anchorages  are  to  be  made  in  the  same  manner,  although  all 
finger  extensions  are  to  be  governed  by  the  same  various  respective 
designs  for  the  given  conditions  at  hand.  The  body  wires  for  lower 
appliances  cannot  vary  under  different  conditions,  however,  because 
of  the  limited  position  which  they  occupy  between  the  inner  surface 
of  the  mandible  and  the  tongue. 


274  PRACTICAL   ORTHODONTIA 

After  the  side  arm  anchorages  are  completed,  the  first  step  in  lower 
body  wire  bending  is  to  bend  the  wire  into  a  U-shape  to  fit  closely 
around  the  lingual  curves  of  the  anterior  segment  of  the  arch  with 
the  ends  pointing  distally.  In  placing  the  anterior  portion  of  this 
heavy  wire,  it  must  be  so  placed  that  the  ends  may  be  bent  back  upon 
themselves  from  points  in  the  region  of  the  most  distal  teeth  engaged 
in  the  anchorage,  running  parallel  with  the  lower  portion  forward, 
and  terminating  about  midway  of  the  most  anterior  anchored  teeth 
engaged  with  spring  clasps. 

If  a  straight  loop  is  placed  low  enough  in  the  sublingual  region,  it 
will  interfere  with  the  motion  of  the  frenum  linguae,  which  will  cut 
into  it  in  a  very  painful  and  damaging  manner.    If  a  straight  loop  is 


Fig.    376. — Anterior  end   of  lower   wire       .    Fig.    377. — Lingual    base    wire    bent    occlusally 
bent    occlusally.      (Fby.)  with    heavy    pliers.       (Eby.) 

placed  higher  than  this  region,  it  is  very  difficult  to  bend  the  ends  for- 
ward and  keep  the  upper  portion  low  enough  to  solder  along  the 
lingual  surface  of  the  posterior  teeth  without  touching  the  lower  por- 
tion of  the  wire  which  it  parallels.  This  renders  it  very  difficult  to 
keep  the  solder  from  running  between  the  wires  and  the  adjustment  is 
made  more  difficult  in  tightening,  if  the  wires  are  very  close  together. 
In  order  to  compromise  between  these  conditions,  it  is  necessary  to 
bend  the  anterior  end  of  the  wire  upward  (Fig.  376).  The  best  method 
of  making  this  bend  is  to  first  bend  the  correct  size  and  shape  around 
the  sublingual  region,  then  by  grasping  the  desired  amount  of  the 
anterior  portion  between  the  jaws  of  the  heavy  parallel  pliers,  the 
bend  can  be  made,  retaining  uniformly  horizontal  relations  between 


REMOVABLE   REGULATING   APPLIANCES 


275 


the  ends  which  point  posteriorly  (Fig.  377).  That  portion  which  is 
bent  upward  can  be  placed  along  the  most  prominent  part  of  the 
ridge  below  the  gum  margin  of  the  anterior  teeth,  allowing  the  ends 
to  run  backward  at  positions  low  enough  for  the  looped  parallel  ends 
to  fold  back  and  rest  no  higher  than  the  gingival  borders  of  the  pos- 
terior teeth  with  about  one-eighth  of  an  inch  between  them,  thus  re- 


Fig  378. — Position  of  lingual  body  wire 
for   lower   appliance.      (Eby.) 


Fig.   379. — Lower  body  wire  with  ends  bent 
anteriorly  held  in  place  with  moldine.    (Eby) 


Fig.  380. — Completed  lower  appliance  with  finger  springs  attached.      (Eby.) 


ducing  the  bulk,  permitting  a  thin  bevel  finish  and  not  interfering 
with  the  tongue  or  pressing  against  the  soft  tissues  (Fig.  378).  The 
final  bend  should  be  made  around  the  nose  of  the  "round-nosed" 
pliers.  Fig.  379  illustrates  the  completed  lower  body  wire  suspended 
in  moldine  slightly  away  from  the  soft  tissues.  Note  that  the  an- 
terior portion  rests  higher  than  the  frenum  linguae  can  reach,  but  at 


276  PRACTICAL   ORTHODONTIA 

the  same  time  low  enough  so  as  not  to  interfere  with  finger  extension 
adjusted  to  the  lingual  surface  of  the  anterior  teeth.  The  body  wire 
should  be  tacked  to  position  with  a  very  small  amount  of  solder  at 
the  posterior  ends  leaving  ample  space  between  the  arms  and  the  up- 
per loops  of  the  wire  to  form  a  groove  into  which  is  soldered  the 
attachment  ends  of  the  finger  springs. 

Fig.  380  illustrates  the  completed  appliance  for  this  case.  It  will 
be  noted  that  the  continuity  of  the  arch  has  been  broken,  shown  at 
present  by  the  absence  of  the  left  first  bicuspid.  The  normal  diameter 
of  this  arch  is  reduced  the  amount  of  the  mesio-distal  diameter  of 
this  missing  tooth.  Under  this  condition,  the  history  of  the  case  may 
reveal  the  early  loss  of  the  deciduous  molar  with  the  resultant  migra- 
tion of  approximating  teeth,  causing  impaction  of  the  premolars.  The 
environments  of  the  teeth  under  the  influence  of  the  tongue  lingually, 
the  buccal  and  labial  muscles,  and  the  occlusal  stress,  have  reduced 
the  size  of  this  arch  in  certain  segments  which  are  normal  and  regular, 
insofar  as  relations  between  the  teeth  in  these  segments  are  concerned. 
If  this  missing  tooth  has  been  extracted  merely  to  correct  a  buccally 
erupted  canine,  the  same  conditions  exist  from  the  corrective  standpoint 
on  the  basis  of  normal  occlusion. 

This  is  a  case  of  neutroclusion,  the  left  molars  and  second  premolars 
having  formed  lingually,  but  they  have  not  moved  mesially.  The  an- 
terior teeth  have  moved  lingually,  proportionately  greater  at  the  left 
canine.  The  left  molars  and  the  second  premolars  are  in  correct  rela- 
tion in  one  segment;  the  anterior  teeth  are  in  correct  relation  in  the 
second  segment;  and  the  right  posterior  teeth  are  in  correct  relation 
in  the  third  segment.  The  three  teeth  comprising  the  left  segment 
are  engaged  with  a  full  spring  clasp  on  the  first  molars  and  two  par- 
tial spring  clasps  on  the  proximal  teeth  soldered  together  on  the  buc- 
cal sides. 

There  is  more  constriction  on  the  left  side  than  on  the  right  side, 
indicating  the  need  of  a  greater  resistance  for  less  expansion  on  the 
right  side ;  therefore,  the  four  posterior  teeth  are  engaged  on  the  right 
side  with  partial  plates  on  the  lingual  surface,  the  first  premolars  bear- 
ing a  pai'tial  clasp,  but  owing  to  the  fact  that  the  right  second  molar  is 
not  fully  erupted,  the  spring  wire  is  placed  on  the  first  molar.  The 
right  canine  rests  as  the  rotary  center  around  winch  the  anterior  teeth 
have  moved  lingually. 

A  finger  spring  is  adapted  to  the  curve  of  the  lingual  surfaces  and 
soldered  into  the  right  arm  of  the  appliance,  terminating  at  the  other 
end  in  the  form  of  a  hook  looped  around  the  distal  proximal  side  of 


REMOVABLE   REGULATING   APPLIANCES  277 

the  left  canine.  These  anterior  teeth  may  be  banded  for  lugs  to  be 
soldered  to  the  lingual  surfaces  for  this  finger  to  snap  beneath,  or  a 
second  lingual  finger  may  be  adjusted  to  rest  above  the  lower  one 
for  the  purpose  of  holding  it  securely  down  to  position  under  active 
pressure.  When  this  lower  spring  is  rendered  active  by  bending  it 
forward  from  the  right  side,  each  anterior  tooth  is  moved  in  a  dif- 
ferent arc  toward  its  normal  position.  The  finger  affords  the  left 
canine  a  long  radius  through  which  it  moves  forward  and  outward  to- 
ward a  straight  line  across  the  arch  opposite  the  right  canine,  to  its- 
correct  position  of  angular  prominence  in  the  parabolic  curve  of  the 
normal  arch. 

The  left  lateral  responds  to  the  path  of  force  applied  on  a  shorter 
radius  than  the  canine,  the  left  central  less  than  the  left  lateral,  the 
right  central  less  than  the  left  central,  and  the  right  lateral  less  than 
the  right  central,  and  the  right  canine  is  only  slightly  turned.  In  this 
way  the  fingers  may  be  so  controlled  as  to  guide  each  tooth  in  a  seg- 
ment of  a  circle  along  entirely  individual  paths  of  movement  toward 
their  normal  positions  in  the  dental  arch. 

By  using  the  posterior  loop  of  the  body  wire  as  rotary  centers,  a 
uniformly  diffused  expansion  can  be  accomplished  between  the  molars 
and  premolars.  If  positive  molar  expansion  is  required,  the  middle 
of  the  anterior  curve  of  the  body  wire  is  bent  open  as  a  rotary  center. 
In  this  way  individual  tooth  movement  can  always  be  perfectly  con- 
trolled under  a  type  of  active  anchorage  which  renders  it  impossible 
for  unexpected  secondary  forces  to  cause  warpage  of  arches  of  de- 
pressions,  elongations,   or   other   displacements   of   any   serious   nature. 

The  removable  appliance  possesses  valuable  features  for  the  correc- 
tion of  irregularities  of  the  deciduous  teeth.  The  correction  of  mal- 
occlusions usually  involves  development  across  the  posterior  side  of 
the  subsequent  anterior  alignment.  The  gingival  constrictions  of  de- 
ciduous teeth  do  not  afford  favorable  undercuts  for  the  spring  clasp 
attachment  for  the  simple  removable  appliance.  It  is,  therefore,  often 
necessaiy  to  use  the  fixed-removable  attachment  on  the  deciduous  teeth. 
Even  with  this  method,  the  technique  of  fitting  simple  bands  to  anterior 
and  posterior  anchor  teeth  on  both  sides  can  be  very  easily  and  effec- 
tively accomplished  in  the  mouths  of  children  between  the  age  of  five 
and  seven,  after  which  the  bands  are  removed  in  a  plaster  impression 
and  the  appliance  finished  out  of  the  mouth. 

In  the  correction  of  malocclusions  during  those  intermediate  years 
between  the  loss  of  deciduous  teeth  and  the  eruption  of  permanent 
teeth  the  removable  appliance  possesses  many  valuable  features.     There 


278 


PRACTICAL    ORTHODONTIA 


is  no  more  favorable  time  for  the  correction  of  malocclusion  than  dur- 
ing the  period  from  seven  to  twelve  years  of  age,  or  during  that  period 
when  deciduous  teeth  are  being  lost  and  the  permanent  teeth  are  taking 
their  position  in  the  dental  apparatus. 

Fig.  381  illustrates  the  lower  arch  with  irregularities  caused  by  the 
early  loss  of  temporary  incisors,  which  has  caused  the  posterior  sides 
to  lose  their  stimulus  and  the  lateral  development  has  not  been  suffi- 
cient. If  the  case  is  allowed  to  remain  in  this  condition,  the  permanent 
lateral  incisors  will  be  crowded  out  of  the  arch  and  forced  to  take 
positions  of  malocclusion.  This  removable  appliance  possesses  full 
spring  clasps  for  the  second  premolars  with  partial  clasps  on  the  first 
premolars  soldered  to  the  full  spring  clasps  on  the  buccal  sides.  The 
body  wire  is  made  of  the  13-gauge  wire.  Small  hook-shaped  extensions 
engage  the  canines.     In  these  two  side  arms  exists  a  uniform  degree 


Fig.   381. — Lower  appliance  constructed  to  pro- 
duce  expansion   in   incisor  region.      (IJby.) 


Fig.   382. — Appliance  constructed  to  exert  pres- 
sure  on   central   and   laterals.      (Eby.) 


of  resistance,  so  that  by  the  mild  but  constant  stimulus  of  the  spring 
force  from  the  body  wire  there  is  produced  the  lateral  development, 
restoring  the  normal  width  and  concentrating  the  space  for  the  nor- 
mal eruption  of  the  lateral  incisors.  If  the  centrals  are  spaced,  new 
finger  springs  may  be  added  at  any  time  with  which  to  draw  them 
together. 

Fig.  382  illustrates  the  removable  appliance  constructed  to  exert 
pressure  upon  the  centrals  and  laterals  which  have  taken  abnormal 
positions.  With  this  type  of  appliance  the  finger  springs  can  be 
changed  any  number  of  times  as  the  treatment  progresses. 

Fig.  383  illustrates  the  anchorage  engaging  the  permanent  molars 
with  the  anterior  portion  of  the  appliance  designed  for  the  lateral  ex- 
pansion of  the  arch  so  as  to  diffuse  the  space  thus  gained  through  the 
anterior  segments  of  the  arch.     After  the  lateral  development  is  ac- 


REMOVABLE    REGELATING    APPLIANCES 


279 


complished,  the  anterior  extension  may  be  replaced  with  "fingers"  to 
perfectly  align  the  incisors  and  in  this  progressive  manner  the  ap- 
pliance can  never  be  too  complicated  to  be  unnecessarily  bulky  and 
the  different  parts  interfere  with  the  work  of  each  other. 

A  great  advantage  of  the  Jackson  appliance  in  cases  at  this  age,  as 
in  many  others,  is  the  ease  with  which  the  appliance  can  be  altered  to 
meet  the  enlarged  dimensions  of  the  growing  arch  and  still  have  the 
appliance  so  constructed  as  to  not  interfere  with  the  eruption  of  teeth, 
for  the  appliance  occupies  a  very  small  space  in  the  oral  cavity.  The 
removable  appliance  possesses  decided  advantage  over  some  fixed  types 


Fig.  383. — Appliance  with  finger 
springs  to  distribute  space  in  incisor 
region.      (Eby.) 


Fig.  384. — Appliance  with  labial 
bow  to  depress  protruding  anterior 
teeth.      (Eby.) 


because  of  the  fact  that  it  exerts  a  gradual  spring  force,  and  should 
the  pressure  be  so  great  at  any  time  as  to  cause  inconvenience  to  the 
patient,  the  nurse  or  parent  can  remove  the  appliance  and  the  child 
will  avoid  the  inconvenience  and  soreness  of  teeth  which  often  accom- 
panies the  fixed  appliance  where  too  much  pressure  is  used  and  the  pa- 
tient is  unable  to  remove  it.  However,  to  accomplish  the  greatest  re- 
sults with  the  removable  appliance  we  must  have  the  cooperation  of  the 
patient.  This  is  not  so  difficult  to  obtain  as  would  be  imagined  because 
of  the  fact  that  the  appliance  is  quite  inconspicuous,  practically  pain- 
less, and  produces  very  little  annoyance. 


CHAPTER  VII 
ANCHORAGE 

Anchorage,  which  may  be  defined  as  the  resistance  used  to  overcome 
an  applied  force,  is  one  of  the  most  important  requirements  of  a  regu- 
lating appliance.  In  orthodontia,  the  applied  force  is  exerted  by  the 
regulating  appliance  upon  the  teeth  that  are  in  malocclusion  and  in  turn 
there  must  be  a  reaction  that  must  be  resisted.  As  action  and  reaction 
are  equal,  the  anchorage  must  be  strong  enough  to  withstand  this  ap- 
plied force. 

Anchorage  is  first  classified  according  to  the  source  of  origin  into  three 
groups — intramaxillary,  intermaxillary,  and  extramaxillary. 

Intramaxillary  anchorage  is  that  form  where  the  resistance  neces- 
sary to  overcome  the  force  required  to  move  the  malposed  tooth  is  ob- 
tained from  a  point  located  in  the  same  arch. 

Intermaxillary  anchorage  is  that  form  where  the  resistance  necessary 
to  overcome  the  force  required  to  move  the  malposed  tooth  is  obtained 
from  a  point  in  the  opposite  arch. 

Extramaxillary  anchorage  is  that  form  where  the  resistance  neeessary 
to  overcome  the  force  required  to  move  the  malposed  tooth  is  obtained 
from  a  point  outside  the  mouth. 

Intramaxillary  and  intermaxillary  anchorage  may  be  divided  or  classi- 
fied according  to  the  number  of  teeth  used  from  which  the  resistance  is 
obtained.  If  but  one  tooth  is  used,  it  is  called  single  anchorage.  If  two 
or  more  teeth  are  used  as  points  of  resistance,  it  is  termed  reenforced 
or  compound  anchorage.  Intramaxillary  and  intermaxillary  anchorage 
may  also  be  divided  with  reference  to  the  manner  in  which  the  resist- 
ance is  obtained :  into  simple,  stationary,  and  reciprocal. 

With  these  definitions  and  plans,  the  following  diagram  has  been  con- 
structed to  show  the  various  combinations  of  anchorage: 

Of  these  various  anchorages,  intramaxillary  is  probably  the  oldest 
variety  that  we  have.  According  to  the  literature  on  the  subject,  extra- 
maxillary anchorage  was  the  next  form  to  be  used  ;  while  intermaxillary 
anchorage  as  used  today  belongs  to  modern  orthodontia. 

280 


ANCHORAGE 


Intramaxillary 


Simple 


Stationary 


Reciprocal 


281 

I  Single,  or  primary 
('(impound,  or  reenforced 
|  Single,  or  primary 
I  Compound,  or  reenforced 
Simple  primary 
Simple  eompound 
Stationary    primary 
Stationary  compound 


Intermaxillary 


Extramaxillary 


Simple 


Single,  or  primary 
('(impound,  or  reenforced 


Stationary    I  Compound 


Reciprocal 

Occipital 
Facial 

Cervical 


Sim [ile  primary 
simple  compound 
stnt  Lonary  compound 


Intramaxillary  Anchorage. — Intramaxillary  anchorage  is  that  form 
of  anchorage  in  which  the  resistance  necessary  to  overcome  the  malposed 
tooth  or  teeth  is  derived  from  a  tooth  or  teeth  located  in  the  same  arch. 

Intramaxillary  anchorage  is  divided  into  simple,  stationary,  and  re- 
ciprocal. 

Simple  Intramaxillary  Anchorage  is  subdivided  into  primary,  or 
single,  and  reenforced,  or  compound,  and  reciprocal  intramaxillary  an- 
chorage into  primary  and  compound.  Stationary  intramaxillary  anchor- 
age may  be  divided  in  the  same  manner. 


282  PRACTICAL   ORTHODONTIA 

Simple  Primary,  or  Single,  Intramaxillary  Anchorage  is  that  form  in 
which  the  resistance  necessary  to  overcome  the  malposed  tooth  is  derived 
from  a  larger  tooth  or  one  more  favorably  located.  Fig.  385  shows  a 
lateral  incisor  that  has  force  exerted  upon  it  by  means  of  an  appliance 
attached  by  primary,  or  single,  simple  intramaxillary  anchorage.  The 
molar,  being  the  largest  tooth  and  more  favorably  located,  overcomes  the 
force  necessary  to  produce  movement  of  the  incisor.  No  other  teeth  are 
employed  to  overcome  the  force,  nor  is  the  appliance  so  constructed  as  to 
aid  the  anchor  tooth. 

Reenforced,  or  Compound,  Simple  Intramaxillary  Ancliorage  is  that 
form  in  which  the  force  necessary  to  produce  movement  of  the  malposed 
teeth  is  overcome  by  two  or  more  teeth,  larger  or  more  favorably  located. 
Fig.  386  shows  where  attachment  is  made  to  the  molars  and  premolars  to 
move  the  premolar  on  the  opposite  side* 


Fig.    385. — Plain    bands    on    lateral    and    molar    teeth    with    jack-screw,    showing    simple    primary 

intramaxillary    anchorage. 

-,  In  simple  anchorage,  either  primary  or  reenforced,  if  sufficient  force 
is  brought  to  bear  upon  the  anchor  tooth  it  will  tip  as  the  attachment  is 
made  in  a  hinge  manner.  If  a  rubber  band  is  stretched  over  two  sepa- 
rated teeth  with  the  object  in  view  of  drawing  one  toward  the  other,  we 
would  have  simple  anchorage,  provided  that  one  tooth  is  larger  and  more 
favorably  located.  In  simple  anchorage  one  of  the  teeth  is  generally  in 
normal  occlusion  and  the  other  in  malocclusion,  for  it  is  intended  to  hold 
the  anchor  tooth  still  and  move  the  malposed  tooth.  Sometimes  simple 
anchorage  is  secured  from  the  molars  that  are  in  normal  mesio-distal  re- 
lation with  the  idea  of  moving  the  anterior  teeth  mesially,  in  which  case 


*Reenforced   simple   intramaxillary   anchorage   is   also    called   compound    simple    intramaxillary 
anchorage. 


ANCHORAGE  283 

the  molars  are  not  disturbed  mesio-distally ;  yet  another  force  may  be 
exerted  to  move  them  buecally.  The  force  that  moves  them  buccally  does 
not  present  them  from  being  used  as  simple  anchorage  in  providing  a 
point  from  which  force  is  exerted  upon  the  incisors.  Therefore  several 
forces  may  be  active  on  the  anchor  teeth  at  one  time. 

One  of  the  disadvantages  of  simple  anchorage  is  that  the  appliance 
cannot  be  assembled  or  constructed  so  as  to  increase  the  stability  of  the 
anchor  tooth.  Care  must  be  exercised  not  to  place  too  much  force  on  the 
anchor  tooth  or  it  will  be  displaced,  much  to  the  chagrin  of  the  operator. 
The  great  number  of  cases  in  which  the  anchor  tootli  was  displaced,  made 


Fig.    386. — Reenforced   simple    intramaxillary   anchorage.      Plain   bands    on   premolar    with   bar    on 
right  premolar  band  to  reenforce  it. 

it  necessary  to  devise  some  form  of  attachment  that  would  be  more  rigid 
and  fixed.  So  after  many  attempts  stationary  anchorage  was  evolved 
and  described  by  Angle. 

Stationary  Anchorage  is  that  form  in  which  the  appliance  is  so  con- 
structed and  attached  to  the  anchor  tooth  that  if  the  anchor  tooth  moves 
at  all,  it  will  move  bodily  through  the  process.  It  has  been  stated  that 
with  the  use  of  simple  anchorage  there  is  danger  of  moving  the  anchor 
tooth.  There  is  not  one  tooth  in  the  mouth  that  is  entirely  immovable,  as 
the  spring  of  the  alveolar  process  and  the  peridental  membrane  allows 
the  teeth  to  be  moved ;  so  it  is  logical  to  expect  that  a  tooth  will  often 
move  slightly  when  used  as  an  anchor  tooth.  If  this  movement  occurs  in 
simple  anchorage  it  is  a  tipping  movement,  but  in  stationary  anchorage 
the  "appliance  is  so  attached  to  the  anchor  tooth"  that  a  tipping  move- 
ment is  impossible.  Not  only  must  the  appliance  be  attached  to  the  an- 
chor tooth  in  such  a  manner  as  to  eliminate  any  "hinge"  movement,  but 


284  PRACTICAL   ORTHODONTIA 

all  parts  of  the  appliance  must  be  so  constructed  as  to  prevent  any  tip- 
ping or  springing  between  the  parts.  As  the  early  regulating  appliances 
were  some  form  of  a  jack-screw  for  pushing  or  a  traction  screw  for  pull- 
ing, the  problems  of  simple  and  stationary  anchorage  were  worked  out 
with  these  appliances.  Therefore  they  are  figured  in  the  illustrations  ac- 
companying this  text  although  they  are  only  occasionally  used  now.  Sta- 
tionary anchorage  was  developed  and  perfected  as  a  matter  of  necessity, 
for  it  dates  back  to  the  time  when  extraction  played  a  large  part  in  the 
regulation  of  teeth.  In  Class  II,  Division  1  cases  (distoclusion  cases  with 
protruding  upper  incisors),  it  was  at  one  time  the  approved  treatment  to 
extract  the  upper  first  premolar  and  to  move  the  canine  and  incisors  dis- 
tally.  Great  force  was  required  to  move  the  canine  distally  and  with 
simple  anchorage  the  molar  was  displaced.     Even  reenforced  simple  an- 


Fig.  387. — Showing  plain  band  on  canine  and  clamp  band  on  molar.  The  long  tube  on  molar 
band  prevents  molar  from  tipping,  hence  if  it  moves  it  must  move  bodily,  as  shown  by  the 
dotted   outline.      The   canine   will    tip. 

chorage  was  not  sufficient  to  provide  enough  resistance  to  overcome  the 
force  necessary  to  "move"  the  malposed  teeth. 

In  order  to  have  stationary  anchorage,  there  are  two  things  that  must 
be  secured,  viz.,  rigidity  and  stability  of  the  appliance.  The  appliance 
must  be  made  from  some  material  that  will  not  bend  under  the  necessary 
force,  and  the  parts  must  be  accurately  fixed  together  and  attached  to 
the  tooth  in  such  a  manner  as  to  prohibit  any  movement  between  the 
tooth  and  the  appliance.  A  molar  band  is  placed  on  the  anchor  tooth 
to  which  the  appliance  is  rigidly  attached.  These  are  the  things  that 
make  stationary  anchorage.  Fig.  387  shows  the  manner  in  which  the 
traction  screw  is  used  with  stationary  anchorage.  The  long  tube  that  is 
soldered  to  the  molar  band  in  which  the  traction  screw  fits  accurately, 


ANCHORAGE 


285 


prevents  any  tipping  of  the  parts.  The  right-angle  end  of  the  screw 
is  attached  to  the  canine  by  engaging  the  tube,  which  is  placed  so  as  to 
make  a  hinge  joint  when  the  force  is  placed  on  the  canine.  In  order  for 
the  molar  to  tip,  the  canine  end  of  the  appliance  would  have  to  move 
gingivally,  which  could  not  occur  unless  the  canine  is  depressed  in  the 
alveolus. 


Fig.  3^S. — Primary  reciprocal  intramaxillary  anchorage. 

Pig.  387  shows  single  stationary  intramaxillary  anchorage.  If  a  band 
was  placed  also  on  the  premolar  and  the  tube  of  the  traction  screw  was 
soldered  to  the  premolar  band  and  the  molar  band,  we  would  then  have 
compound  stationary  intramaxillary  anchorage. 

KiX'iPROCAL  Anchorage  is  that  form  in  which  the  force  necessary  to 
move  a  malposed  tooth  is  derived  from  another  malposed  tooth,  with  the 


389. — Another   form    of    primary    reciprocal    anchorage.      The    centrals    will    be    the    teeth    to 

move. 


idea  that  both  be  made  to  assume  a  proper  position  in  the  line  of  occlu- 
sion. Fig.  388  shows  two  canines  in  lingual  occlusion.  A  jack-screw 
placed  between  them  would  exert  pressure  in  such  a  manner  as  to  move 
both  of  them  buccally.  One  of  the  canines  may  move  more  easily  than  the 
other,  in  which  case  some  other  means  must  be  employed  to  increase  the 
resistance  of  the  easilv  moving  tooth.     These  things  will  be  mentioned 


L'Nli  PRACTICAL   ORTHODONTIA 

Later.  A  rubber  band  placed  around  the  central  incisors  that  are  sepa- 
rated gives  us  reciprocal  anchorage.  Reciprocal  anchorage  is  divided 
into  primary,  or  single,  and  compound.     It  may  also  be  divided  into 

simple  and  stationary. 


Fig.    390. — Compound    reciprocal    intramaxillary    anchorage. 


Fig.   391. — The  use  of  the  expansion  arch  generally  embodies   compound   reciprocal   intramaxillary 

anchorage. 


Primary,  or  Single,  Reciprocal  Intramaxillary  Anchorage  is  that  form 
in  which  the  appliance  is  attached  to  but  one  malposed  tooth  on  each  side 
with  the  object  in  view  of  moving  only  those  teeth  to  which  the  appliance 
is  attached  (Fig.  388) .  A  wire  passed  around  the  teeth,  as  shown  in  Fig. 
389,  is  primary  or  single,  reciprocal  anchorage. 


ANCHORAGE 


287 


Compound  Reciprocal  Intramaxillary  Anchorage  is  that  form  in  which 
the  appliance  is  so  constructed  that  other  teeth  are  moved  besides  the  one 
to  which  the  appliance  is  attached.  Fig.  390  shows  a  jack-screw  attached 
to  a  band  on  the  second  premolar  with  a  lingual  bar  soldered  to  the  band 


Fig.   393. 

Figs.    392    and    393. — Removable    appliances    employing    compound    reciprocal    intramaxillary    an- 
chorage. 

resting  against  the  molar,  premolar  and  canine,  which  will  move  the 
teeth  on  each  side  buccally.  The  appliance  used  is  exactly  the  same  as 
shown  in  Fig.  388,  yet  several  teeth  are  being  moved  when  only  two 
were  moved  with  primary,  or  single,  reciprocal  intramaxillary  anchor- 


288 


PRACTICAL    ORTHODONTIA 


age.  The  author  lias  used  the  same  appliance  in  most  of  the  anchorages 
described  to  show  that  anchorage  does  not  depend  upon  certain  appli- 
ances. Different  appliances  can  be  constructed  and  used  with  these  an- 
chorages to  meet  the  requirements  of  the  cases. 


Fig.    394. 


Fig.    395. 

Figs.    394    and    395. — Removable    appliance    employing 

chorage. 


compound     reciprocal     intramaxillary    an- 


Compound  reciprocal  intramaxillary  anchorage  is  the  form  employed 
when  the  expansion  arch  is  used,  as  shown  in  Fig.  391.  It  is  also  the  an- 
chorage employed  in  the  use  of  the  regulating  appliance  shown  in  Figs. 
392,  39"3,  394,  and  395.  In  fact,  it  is  used  in  nearly  all  cases  of  maloc- 
clusion. To  be  exact,  the  use  of  the  expansion  arch  as  shown  in  Fig.  391 
evolves  simple  compound  reciprocal  intramaxillary  anchorage. 


ANCHORAGE  289 

Reciprocal  anchorage  is  further  divided  into  simple  reciprocal  and 
stationary  reciprocal. 

Simple  Reciprocal  Intramaxillary  Anchorage,  either  primary  or  com- 
pound, is  where  the  attachment  is  made  to  the  anchor  tooth  or  teeth  in 
such  a  manner  that  the  teeth  can  tip.  Fig.  396  shows  an  expansion  arch 
or  spring  attached  to  two  canines  with  the  object  in  view  of  moving  them 
buccally.  The  tubes  are  so  placed  that  the  teeth  will  tip  because  there 
is  a  hinge  motion  possible  between  the  arch  and  the  tube  on  the  band. 

Stationary  Reciprocal  Intramaxillary  Ancliorage,  either  primary  or 
compound,  is  that  form  in  which  the  appliance  is  attached  to  the  anchor 
teeth  in  such  a  manner  that  they  will  be  moved  bodily  through  the  proc- 
ess. Figs.  397  and  398  illustrate  the  same  small  expansion  arch  as  shown 
in  Fig.  396,  which  is  again  attached  to  two  canines,  but  the  tube  is  so 


Fig.    396. — Simple   reciprocal    intramaxillary    anchorage    that   allows    anchor    teeth    to    tip. 

placed  on  the  bands  and  the  end  of  the  arch  bent  in  such  a  way  that  the 
canines  are  moved  bodily.  In  cases  where  the  molars  are  to  be  moved 
bodily,  an  arch  with  a  square  end  and  a  tube  that  is  square  on  the  inside 
make  stationary  reciprocal  anchorage  on  the  molars  with  the  expansion 
arch  (Fig.  399). 

The  use  of  the  ordinary  expansion  arch  with  round  ends  and  the  wire 
ligatures  embodies  simple  compound  reciprocal  intramaxillary  anchor- 
age.    This  is  the  most  generally  used  form  of  anchorage. 

Intermaxillary  Anchorage. — Intermaxillary  anchorage  has,  been  de- 
fined as  that  form  in  which  the  resistance  necessary  to  overcome  the  mal- 
posed  tooth  or  teeth  is  derived  from  a  tooth  or  teeth  located  in  the  oppo- 


290 


PRACTICAL    ORTHODONTIA 


site  arch.  In  other  words,  the  malposed  tooth  and  the  anchorage  are  in 
different  arches.  Intermaxillary  anchorage  is  the  newest  form  that  we 
have  and  has  done  more  to  eliminate  the  extraction  of  teeth  than  any 
other.  It  offers  many  combinations  and  is  the  least  understood  of  any 
of  the  anchorages  by  the  majority  of  practitioners. 


Fig.   397. 


Fig.    398. 

Figs.    397    and    398. — Stationary    reciprocal    intramaxillary    anchorage.      Anchor    teeth    must 

move  bodily. 

In  regard  to  the  number  of  teeth  moved,  intermaxillary  anchorage  is 
divided  into  primary  and  compound,  and  in  regard  to  the  manner  of 
movement,  into  simple,  stationary  and  reciprocal. 

Primary  Simph   Intermaxillary  Anchoragt   is  employed  when  a  tooth 


ANCHORAGE 


291 


in  one  arch  is  used  to  overcome  the  force  necessary  to  move  a  tooth  in 
the  opposite  arch.  It  is  employed  in  moving  teeth  that  are  in  infra-oc- 
clusion. An  example  is  shown  in  Fig.  400,  where  the  canine  is  in  infra- 
occlusion  and  the  anchorage  is  obtained  from  the  lower  premolar. 

Compound  Simple  Intermaxillary  Anchorage  is  that  form  in  which 
one  or  more  teeth  in  one  arch  are  moved  by  force  derived  from  teeth  in 
the  opposite  arch.  This  is  shown  in  Fig.  401,  in  which  case  the  central 
incisor  is  in  infra-occlusion  and  the  force  in  derived  from  the  lower  teeth. 

Primari/  Reciprocal  Intermaxillary  Anchorage  is  that  form  in  which 


Fig.    399. — The  square  tube  and   arch   used  on   molars   make   stationary   anchorage   on   the   molars. 
Oval   buccal    tube   shown   above,    square   buccal    tube    below. 


the  force  necessary  to  move  a  malposed  tooth  in  one  arch  is  derived  from 
a  malposed  tooth  in  the  opposite  arch,  the  force  causing  both  to  assume 
a  proper  position  in  the  line  of  occlusion.  An  upper  and  lower  canine 
that  are  in  infra-occlusion,  as  shown  in  Fig.  402,  is  an  example  of  this 
anchorage.  Such  eases  as  illustrated  here  are  seldom  seen,  as  there  is 
generally  some  other  malocclusion  present  demanding  treatment  at  the 
same  time. 

Compound  Reciprocal  Intermaxillary  Anchorage  is  that  form  in  which 
two  or  more  malposed  teeth  of  one  arch  are  pitted  against  two  or  more 
teeth  in  the  opposite  arch  for  the  purpose  of  causing  both  to  assume  a 


292 


PRACTICAL    ORTHODONTIA 


proper  position  in  the  line  of  occlusion.  This  form  of  anchorage  could 
be  used  when  the  six  anterior  teeth  of  the  upper  and  lower  arch  are  in 
infra-occlusion,  as  illustrated  in  Fig.  403.  However,  it  is  very  seldom 
that  we  find  such  conditions  that  demand  an  equal  movement  of  the 
upper  and  lower  anterior  teeth.  The  most  frequent  use  of  compound 
reciprocal  intermaxillary  anchorage  is  in  the  treatment  of  Class  II,  or 
distoclusion,  and  Class  III,  or  mesioclusion  cases,  and  according  to  the 
early  literature  on  the  subject,  this  was  the  manner  in  which  it  was  em- 
ployed. It  also  appears  to  have  been  used  in  this  way  by  Baker  and 
later  called  "Baker  Anchorage"  by  Angle.    When  all  of  the  teeth  in  one 


Fig.     400. — Primary    simple    intermaxillary 
anchorage. 


Fig.    401. — Compound    simple    intermaxillary 
anchorage. 


Fig.    402.— Primary   reciprocal    intermaxillary       Fig.    403. — Compound   reciprocal    intermaxillary 
anchorage.  anchorage. 


arch  are  pitted  against  all  of  the  teeth  in  the  opposing  arch,  with  the  ob- 
ject in  view  of  moving  the  teeth  in  both  arches,  this  form  of  anchorage 
is  the  one  usually  employed,  as  shown  in  Figs.  404  and  405.  It  is  possible 
to  use  compound  reciprocal  intermaxillary  anchorage  by  pitting  a  certain 
number  of  the  teeth  in  one  arch  against  a  certain  number  of  teeth  in 
the  opposing  arch.  This  does  not  mean  that  the  same  kind  of  teeth  in 
one  arch  are  pitted  against  the  same  kind  of  teeth  in  the  other.  In  Fig. 
406  is  shown  a  case  in  which  it  was  necessary  to  move  the  superior  in- 
cisors distally  and  the  lower  premolars,  canines  and  incisors  mesially. 
This  was  accomplished  by  using  compound  reciprocal  intermaxillary 


ANCHORAGE 


293 


Fig.   404. 


Fig.   40S. 
Figs.  404  and   40S. — Compound  reciprocal   intermaxillary  anchorage  used  with   expansion   arches. 


294  PRACTICAL,   ORTHODONTIA 

anchorage,  the  application  of  which  is  described  in  Chapter  XI.  This 
form  of  intermaxillary  anchorage  should  also  be  called  simple,  the  teeth 
being  attached  in  such  a  manner  as  to  permit  tipping. 

Stationary  Intermaxillary  Anchorage  is  that  form  in  which  the  at- 
tachment is  made  to  the  anchor  teeth  in  one  arch  in  such  a  manner  that 
if  they  move  at  all  they  must  be  dragged  bodily  through  the  process,  the 
anchor  teeth  and  the  moving  teeth  being  in  different  arches.  This  form 
of  anchorage  is  obtained  by  constructing  and  applying  the  appliance  in 
such  a  manner  as  to  make  tipping  impossible  and  is  the  outgrowth  of 
simple  compound  reciprocal  intermaxillary  anchorage.     It  was  found  in 


Fig.   406. — An  ideal   case  for  the   use   of   compound    reciprocal   intermaxillary   anchorage. 

the  treatment  of  certain  cases  that  the  mandibular  teeth  moved  forward 
more  rapidly  than  the  maxillary  teeth  moved  distally.  In  order  to  stop 
the  movement  of  the  mandibular  teeth  it  becomes  necessary  to  make  them 
stationary,  which  was  done  by  the  proper  construction  and  attachment 
of  the  appliance.  This  greatly  increased  the  movement  of  the  maxillary 
teeth,  while  the  mandibular  teeth  remained  immovable.  If  bands  are 
placed  on  the  maxillary  and  mandibular  molars  and  the  arches  applied 
with  intermaxillary  rubbers,  as  shown  in  Fig.  4,04,  we  would  have  com- 
pound reciprocal  intermaxillary  anchorage  of  the  simple  form.  This 
form  of  anchorage  would  permit  a  tipping  of  the  maxillary  and  man- 
dibular teeth,  which  would  make  it  simple  anchorage.    As  stated  before, 


ANCHORAGE  295 

the  maxillary  teeth  would  not  move  as  rapidly  as  the  mandibular  and  by 
bending  the  anterior  part  of  the  lower  arch  gingivally,  also  placing  wires 
around  the  anterior  mandibular  teeth,  which  would  spring  the  arch  up- 
ward to  its  proper  position,  a  backward  force  would  be  exerted  upon 
the  mandibular  molar  that  would  overcome  the  forward  pull  of  the  in- 
termaxillary rubbers.  The  tipping  stress  exerted  upon  the  mandibular 
molars  by  the  bent  arch  and  the  wires  on  the  lower  anterior  teeth  spring- 
ing the  anterior  portion  upward,  converts  the  anchorage  into  a  stationary 
one  on  the  lower  teeth.  The  maxillary  teeth  can  still  tip.  The  manner  of 
bending  the  arch  and  wiring  it  is  shown  in  Fig.  407. 

As  soon  as  the  lower  appliance  is  adjusted,  as  shown  in  Fig.  407,  the 
anchorage  is  no  longer  reciprocal  as  the  mandibular  molars  stop  tipping-. 
By  making  the  attachment  on  the  lower  arch,  as  shown  in  Kg.  694,  the 
lower  anterior  teeth  are  also  prevented  from  tipping  and  must  move 
bodilv.     This  forms  stationary  attachment  to  the  lower  teeth. 


Fig.  407. — Showing  manner  of  bending  lower  arch  gingivally  and  then  springing  occlusally 
to  make  lower  molars  stationary.  Dotted  line  indicates  position  that  lower  arch  will  occupy 
when   sprung   occlusally. 

It  is  very  seldom  that  the  teeth  of  both  arches  are  moved  bodily  to 
the  same  extent.  What  generally  occurs  is  that  the  teeth  of  one  arch 
are  made  rigid  by  the  attachment  of  the  appliance  so  as  to  prevent  move- 
ment and  the  teeth  of  the  other  arch  are  so  attached  to  the  appliance 
that  they  will  move  bodily.  This  would  then  be  only  another  form  of 
compound  stationary  intermaxillary  anchorage.  An  example  of  the 
stationary  attachment  of  teeth  in  both  arches  is  seen  in  Fig.  325,  which 
is  a  Class  II,  Division  1  (distoclusion,  with  labioversion  of  the  upper 
anterior  teeth)  case.  It  has  been  found  that  the  best  results  in  these 
cases  are  obtained  by  not  moving  the  mandibular  molars  and  canines 
distally,  and  moving  the  entire  lower  arch  or  teeth  mesially  the  entire 


296 


PRACTICAL    ORTHODONTIA 


distance  necessary  to  establish  normal  occlusion.  Also,  the  best  facial  re- 
sults and  masticating  apparatus  are  obtained  by  moving  the  lower  teeth 
bodily.  Bands  are  placed  on  the  mandibular  and  maxillary  molars.  The 
upper  arch  is  ligated  to  all  of  the  maxillary  teeth  in  such  a  manner  as  to 


Fig.  40S. — Occipital  extramaxillary   anchorage.      (Angle.) 


Fig.    409. — Occipital   extramaxillary   anchorage.      (Angle.) 


ANCHORAGE  297 

prevent  the  maxillary  molars  from  tipping.  If  the  anterior  portion  of 
the  upper  expansion  arch  cannot  move  occlusally,  the  molars  cannot 
tip.  The  lower  expansion  arch  is  also  wired  to  the  mandibular  teeth  so 
as  to  prevent  tipping  of  the  molars ;  to  prevent  tipping  of  the  incisors, 
spurs  are  placed  on  the  lower  arch  and  the  incisors  wired  to  them  in  such 
a  manner  as  to  hold  the  teeth  perpendicular  with  the  spurs,  as  shown  in 
Fig.  706.  The  advantage  of  stationary  compound  intermaxillary  anchor- 
age whether  used  reciprocally  or  not  is  very  great  and  is  the  last  form 
of  intermaxillary  anchorage  to  he  introduced. 


Fig.    410.— Cervical    anchorage.      (Carl    Case.) 

Extramaxillary  Anchorage. — Extramaxillary  anchorage  is  that  form 
in  which  the  resistance  necessary  to  overcome  the  malposed  tooth  or 
teeth  is  derived  from  some  source  outside  the  oral  cavity.  It  offers  the 
most  immovable  base  that  can  be  obtained.  The  principal  objection  is 
the  appearance  of  the  appliance.  There  are  three  types  of  extramax- 
illary anchorage — occipital,  facial  and  cervical. 

Occipital  Anchorage  is  where  the  force  necessary  to  overcome  the  mal- 
posed tooth  is  derived  from  tbe  occipital  region.  This  is  one  of  the  oldest 
forms  of  anchorage  of  which  we  have  a  record.  It  was  first  used  with 
an  ordinary  night-cap  and  was  improved  and  modified  by  various  means 
until  we  find  the  most  ideal  form  as  designed  by  Angle.  (See  Figs.  408 
and  409.) 

Facial  Anchorage  is  where  force  necessary  to  overcome  the  malposed 
teeth  is  derived  from  the  facial  bones.     This  anchorage  was  introduced 


298  PRACTICAL    ORTHODONTIA 

by  V.  E.  Barnes  and  consists  of  a  device  which  rests  against  the  molar 
bones  and  forehead. 

Cervical  Anchorage  was  introduced  and  first  applied,  to  the  author's 
knowledge,  by  Carl  Case  (Fig.  410),  and  is  that  form  in  which  the  force 
necessary  to  overcome  the  malposed  teeth  is  derived  from  the  cervical 
vertebrae  (Fig.  410).  Occipital  anchorage  was  used  in  those  cases  that 
demanded  a  distal  movement  of  the  anterior  teeth.  It  was  used  on  the 
superior  anterior  teeth,  as  shown  by  Fig.  408,  and  by  means  of  the  chin 
cap  (Fig.  409)  the  pressure  was  exerted  on  the  mandible.  It  was  also 
used  to  exert  pressure  on  the  mandibular  anterior  teeth,  but  there  was  a 
tendency  to  elongate  the  mandibular  anterior  teeth.  It  was  to  overcome 
this  tendency  to  elongate  the  mandibular  anterior  teeth  that  cervical  an- 
chorage was  devised.  Facial  anchorage  was  devised  to  move  the  teeth 
mesially,  and  is  valuable  in  those  cases  that  demand  the  forward  move- 
ment of  the  upper  and  lower  molars.  If  one  is  able  to  use  the  various 
other  anchorages  as  they  should  be  used,  there  is  little  need  for  extra- 
maxillary  anchorage. 

Owing  to  the  fact  that  reciprocal  anchorage  utilizes  all  of  the  force  ex- 
erted on  the  malposed  teeth,  it  is  the  most  useful  form  of  anchorage. 
With  intermaxillary  anchorage  in  the  various  compound,  reciprocal,  and 
stationary  forms,  we  are  able  to  get  tooth  movement  in  any  particular 
direction  desired.  Simple  anchorage  is  the  easiest  to  obtain  but  not 
always  sufficient  for  the  needs  of  the  case.  Stationary  anchorage  re- 
quires a  greater  understanding  of  mechanics  than  any  other  form.  The 
principal  and  most  useful  forms  of  anchorage  will  be  considered  in  the 
chapter  on  treatment  of  cases. 


CHAPTER  VIII 

RETENTION  OF  TEETH 

It  has  been  said  that  the  problem  of  modern  orthodontia  is  one  of  re- 
tention. With  the  modern  regulating  appliances  it  becomes  quite  easy 
to  regulate  teeth,  but  to  keep  them  in  their  new  position  has  been  diffi- 
cult. 

Forces  of  Retention 

Retention  is  the  application  of  force  to  maintain  teeth  in  their  proper 
position  in  the  line  of  occlusion.  Not  only  must  the  teeth  be  retained 
in  position  in  the  line  of  occlusion,  but  they  must  often  have  force  ex- 
erted upon  them  to  assist  them  in  assuming  different  angles  and  lengths 
than  are  present  immediately  after  the  regulating  appliance  is  removed. 
It  has  been  said  that  retention  is  the  application  of  force  to  maintain 
and  produce  normal  occlusion.  It  must  be  remembered  that  teeth 
are  not  held  rigid  in  the  dental  apparatus  but  are  constantly  moving 
under  the  stress  of  mastication-;  also  that  they  are  held  in  position  by 
the  forces  of  occlusion  and  are  constantly  changing  positions  during 
the  growth  of  the  individual.  Therefore  the  force  exerted  upon  the 
teeth  during  retention  must  be  exerted  with  that  idea  in  view. 

The  forces  of  retention  are  mechanical  and  natural. 

Mechanical  Forces 

Mechanical  forces  are  those  that  are  exerted  by  artificial  devices. 
They  exert  force  until  the  natural  forces  can  establish  themselves,  for 
it  must  be  remembered  that  all  cases  of  malocclusion  are  the  result 
of  interference  with  some  of  the  forces  of  occlusion.  In  other  words, 
some  one  of  the  natural  forces  of  retention  has  not  been  active. 

Mechanical  forces  are  divided  into  active  and  passive. 

Passive  Mechanical  Forces  are  those  that  antagonize  the  backward 
tendency  of  the  teeth  only,  and  do  not  exert  any  force,  simply  resisting 
the  efforts  of  the  teeth  to  return  to  their  former  position.  Angle  has 
said  that  teeth  should  be  retained  against  their  backward  tendency  only. 
This  backward  tendency  of  the  teeth  can  be  prevented  by  the  use  of 
passive  force. 

Active  Mechanical  Force  is  obtained  by  the  use  of  an  appliance  that 

299 


300  PRACTICAL    ORTHODONTIA 

possesses  some  force  in  itself,  and  a  constant  force  is  being  exerted  by 
the  retaining  appliance  equal  to  that  exerted  by  the  backward  tendency 
of  the  teeth.  The  advantage  of  such  a  force  enables  us  to  use  a  more 
delicate  appliance,  gives  us  a  chance  to  regulate  the  force  exerted  upon 
the  teeth,  and  permits  the  teeth  to  move  under  the  stress  of  mastication, 
as  a  result  of  which  they  assume  normal  positions  more  readily,  by 
the  natural  forces  of  retention  or  occlusion  being  able  to  exert  them- 
selves. 

Besides  being  divided  into  active  and  passive  forces,  mechanical  ap- 
pliances are  divided  into  intramaxillary,  intermaxillary,  and  extramax- 
illary. 

Intramaxillary  Retention  is  where  the  mechanical  force  necessary  to 
overcome  the  backward  tendency  of  the  teeth  in  one  arch  is  derived 
from  a  tooth  or  teeth  in  the  same  arch.  It  may  be  either  active  or 
passive. 

Intermaxillary  Retention  is  where  the  force  necessary  to  overcome 
the  backward  tendency  of  the  teeth  is  derived  from  teeth  in  the  oppo- 
site arch.    It  may  be  active  or  passive. 

Extramaxillary  Retention  is  where  the  force  necessary  to  overcome 
the  backward  tendency  of  the  teeth  is  derived  from  some  source  out- 
side of  the  oral  cavity.    This  is  always  an  active  force. 

Intramaxillary  retention  is  divided  into  simple,  reciprocal  and  sta- 
tionary. Reciprocal  is  again  divided  into  primary  and  compound. 
Stationary  should  not  be  used  as  it  holds  the  teeth  too  rigid. 

Intermaxillary  retention  is  also  divided  into  simple,  reciprocal  and 
stationary.    Reciprocal  is  again  divided  into  primary  and  compound. 

Extramaxillary  retention  is  divided  into  occipital,  cervical  and  facial. 
No  form  of  extramaxillary  retention  is  often  used. 

With  this  outline  of  mechanical  retention  we  will  take  up  the  prin- 
ciples of  the  natural  forces,  which,  it  must  be  remembered,  are  the 
final  solution  to  the  retention  of  teeth. 

Natural  Forces 

The  natural  forces  of  retention  are  the  same  as  the  forces  of  occlu- 
sion, as  follows : 

1.  The  force  of  the  inclined  plane. 

2.  Harmony  in  the  size  of  the  arches. 

3.  Normal  muscular  pressure. 

4.  Normal  approximal  contact. 

5.  Normal  cell  metabolism. 

6.  Normal  atmospheric  pressure. 


RETEXTIOX    OF    TEETH  301 

Taking  the  forces  more  in  the  order  given  above  than  in  their  order 
of  importance,  for  it  is  hard  to  say  which  is  the  most  important,  we  will 
begin  with  one  with  which  all  are  familiar,  viz.,  the  "Normal  relation 
of  the  inclined  plane." 

Force  of  the  Inclined  Plane. — Since  so  much  has  been  written  on  this 
as  a  force  of  occlusion,  it  will  be  unnecessary  here  to  go  into  details. 
Eowever,  the  author  wishes  to  caution  the  reader  again  that  the  lingual 
cusps  are  as  important  as  are  the  buccal  cusps.  We  must  keep  in  mind 
the  various  shapes  of  the  teeth,  especially  the  lower  premolars ;  also 
the  position  that  they  occupy  in  the  arch. 

Fig.  411  shows  the  different  shapes  of  the  mandibular  second  pre- 
molars. They  are  illustrations  made  from  a  skull  and  model  in  the 
author's  possession.  The  lower  second  premolar  with  three  cusps  is 
not  so  rare  as  might  be  supposed  and  each  cusp  has  a  definite  occlu- 
sion. 


Fig.    411. — Different   shapes    of   mandibular   premolars,    which    must   be    considered   in    retention. 

We  must  also  take  into  consideration  the  fact  that  the  lower  premo- 
lars do  not  occupy  the  same  angle  of  inclination  as  do  the  upper  pre- 
molars (Fig.  412).  A  line  drawn  through  the  buccal  and  lingual  cusps 
of  the  upper  premolars  would  nut  be  parallel  to  one  passing  through 
the  lower  premolars.  The  line  from  the  lower  premolars  would  cross 
with  the  apex  of  the  angle  to  the  lingual  of  the  teeth.  It  is  the  au- 
thor's opinion  that  in  a  great  many  cases,  the  lingual  cusp  of  the  lower 
first  premolar  has  been  moved  too  far  mesially  in  the  attempt  to  get 
it  parallel  with  the  upper.  This  change  has  invited  the  distal  surface 
of  the  lower  canine  to  turn  buccally.  These  things  we  must  watch,  for 
the  influence  of  the  inclined  planes  in  holding  the  teeth  is  well  under- 
stood. AVe  can  even  determine  at  the  beginning  of  the  case  by  observ- 
ing the  length  of  the  cusps  whether  we  will  have  any  difficulty  whatso- 


302  PRACTICAL   ORTHODONTIA 

ever  in  getting  the  natural  forces  of  occlusion  to  assert  themselves. 
Also,  in  speaking  of  the  length  of  the  cusps  in  relation  to  the  forces 
of  the  inclined  planes  as  a  factor  in  retention,  we  should  not  forget  the 
importance  of  the  length  of  the  cusps.  In  order  that  we  may  not  have 
undue  trouble  in  getting  the  teeth  to  remain  where  we  desire  them,  and 
in  order  that  the  forces  of  the  inclined  planes  be  exercised  to  their  full- 
est capacity,  we  must  be  sure  that  the  length  of  the  overbite  be  no 
greater  than  the  length  of  the  buccal  cusps  of  the  molars  and  pre- 
molars. In  other  words,  when  the  anterior  teeth  are  edge  to  edge, 
the  tips  of  the  buccal  cusps  should  just  touch.  By  studying  a  great 
many  models,  we  shall  find  when  the  cases  are  retained  that  we  do  not 
always  have  that  condition,  and  in  those  cases  in  which  it  does  occur, 
experience  will  prove  that  they  are  the  ones  in  which  we  have  our  best 
results ;  they  are  the  ones  from  which  we  have  been  able  to  remove  the 
retaining  appliance  early.  If  the  length  of  the  overbite  is  not  the 
same  as  the  length  of  the  buccal  cusps  of  the  molars  and  premolars, 


Fig.   412. — Showing  the  different  angles   that   the   lower  and  upper  premolars   occupy   in  the  arch. 

we  must  so  adjust  the  retaining  appliance  that  the  teeth  will  be  forced 
to  assume  the  normal  position.  Great  care  must  be  exercised  in  mak- 
ing the  retaining  appliance  so  as  to  assist  and  permit  the  overbite  of 
the  teeth  to  become  normal.  In  this  class  of  cases,  the  importance  of 
the  active  mechanical  retaining  appliance  becomes  apparent.  The 
force  of  the  inclined  plane  with  reference  to  the  overbite  and  as  a 
factor  in  retention,  will  be  again  taken  up  in  conjunction  with  the  ap- 
proximal  contact  point. 

Harmony  in  the  Size  of  the  Arches. — In  speaking  of  harmony  in  the 
size  of  the  arches  in  retention,  very  little  need  be  said,  for  if  the  reader 
is  familiar  with  normal  occlusion,  he  should  understand  the  impor- 
tance of  this  force  of  retention.  However,  in  order  that  the  reader  may 
better  appreciate  this  condition,  the  author  will  call  attention  to  sev- 
eral cases  in  which  this  one  factor  has  been  neglected.  It  is  true  that 
harmony  in  the  size  of  the  arches  cannot  be  disturbed  without  throw- 


RETENTION    OF    TEETH 


303 


ing  out  some  other  force  to  a  certain  extent.     The  importance  of  keep- 
ing- the  proper  mesio-distal  relation  of  the  teeth  in  all  cases,  in  order 


Fig.    413. 


Fig.   414. 

Figs.    413   and   414. — Inharmony   in  size  of  arches   produced  by  extraction,  making  the   establish- 
ment   of    normal    occlusion   impossible,    also    interfering   with    retention. 


304  PRACTICAL    ORTHODONTIA 

that  we  may  have  the  proper  size  of  each  arch,  is  as  important  in  the 
deciduous  as  in  the  permanent  teeth.  The  evils  of  extraction  are  so 
apparent  that  it  is  hardly  necessary  to  mention  them.  Aside  from  de- 
stroying the  facial  contour  and  expression  of  the  patient,  extraction 
renders  the  establishment  of  normal  occlusion  impossible,  because  it 
forever  destroys  the  possibility  of  again  having  harmony  in  the  size 
of  the  arches.  Owing  to  the  fact  that  no  two  teeth  in  both  arches  are 
exactly  the  same  size,  the  arches  would  not  be  of  equal  size  should  any 
of  the  teeth  be  extracted.  Therefore,  when  in  a  "fit  of  wisdom"  some 
one  takes  out  different  teeth  in  opposite  arches,  normal  occlusion  be- 
comes a  thing  impossible  for  that  patient  without  artificial  substitutes. 
The  case  shown  in  Figs.  413  and  414  is  one  of  this  kind.    Fig.  415  shows 


Fig.   415. — Inharmony   of  arches   produced   by  the   prolonged   retention   of  mandibular   second 

premolar. 

a  ease  with  a  lower  second  molar  retained  too  long.  An  x-ray  showed 
that  the  premolar  is  absent.  The  normal  relation  of  the  teeth  can  be 
seen  in  the  models,  but  the  molars  did  not  remain  as  shown.  Because 
the  mandibular  molar  was  held  distally  at  the  time  of  the  eruption  of 
the  maxillary  second  molar,  the  first  molar  was  carried  forward  as  it 
should  have  been  and  now  the  mandibular  is  distal  to  normal,  not  be- 
cause there  was  not  proper  locking  of  the  molar  cusps,  but  because 
of  the  inharmony  in  the  size  of  the  arches.  In  the  latter  case,  regard- 
less of  how  long  mechanical  retention  would  be  enjoyed,  normal 
occlusion  of  all  of  the  teeth  could  not  be  maintained  when  the  retainer 


RETENTION    OF    TEETH  305 

was  removed,  because  of  the  missing  natural  force  of  retention.  This 
brings  us  to  the  important  fact  that  all  fillings  and  artificial  substitutes 
should  have  the  proper  mesio-distal  diameter  as  well  as  the  proper  in- 
clined plane  and  normal  approximal  contact.  In  fact,  if  one  force  is 
missing,  some  of  the  others  will  soon  be  thrown  out  of  balance. 

Normal  Muscular  Pressure. — The  importance  of  normal  muscular 
pressure  is  well  shown  in  any  case  in  which  the  patient  is  a  mouth- 
breather.  Of  course,  some  of  the  deformity  that  we  see  in  those  cases 
is  the  result  of  abnormal  atmospheric  pressure.  Nevertheless  we  must 
have  the  harmonious  action  of  the  lips  and  tongue  in  order  that  normal 
occlusion  may  be  maintained.  The  great  amount  of  deformity  that  we 
find  in  cleft  palates  is  the  result  of  the  muscular  pressure  that  has  no 
constraining  influence.  Likewise,  in  abnormal  frenums,  we  see  the 
effect  of  abnormal  muscular  action  caused  by  the  abnormal  attachment 
of  the  frenum.  We  also  find  cases  of  large  tongues  that  produce  mal- 
occlusions. These  cases  must  be  treated  with  the  object  in  view  of  get- 
ting the  teeth  in  such  a  position  that  when  they  are  retained  the  mus- 
cular pressure  will  be  normal.  Cases  that  are  the  result  of  tongue  and 
lip  habits  are  very  difficult  to  retain  because  these  habits  destroy  the 
normal  muscular  relations. 

The  importance  of  the  action  of  the  various  muscles  as  a  factor  in 
producing  and  maintaining  the  proper  relation  of  the  teeth  has  long 
been  a  recognized  fact.  It  is  one  that  has  also  been  improperly  under- 
stood. It  should  be  remembered  that  we  have  but  four  pair  of  mus- 
cles of  mastication.  They  are  all  attached  in  the  region  of  the  ramus, 
that  is,  they  are  inserted  into  some  portion  of  the  ramus  or  angle ;  none 
of  them  are  inserted  forward  into  the  body  of  the  bone.  Therefore,  all 
of  the  force  that  they  exert  on  the  body  of  the  mandible  must  be 
transmitted  through  the  teeth  during  mastication.  If  we  have  mal- 
occlusion, we  shall  not  find  the  proper  development  of  the  body  of  the 
mandible  because  of  the  improper  stimulation  as  a  result  of  the  im- 
proper muscular  force.    This  is  especially  true  in  Class  II  and  III  cases. 

The  muscles  of  expression  play  an  important  part  in  maintaining  oc- 
clusion and  their  action  is  almost  entirely  confined  to  the  eight  an- 
terior teeth.  This  is  easily  understood  when  we  consider  that  all  of 
the  muscles  of  expression,  except  the  levator  menti,  are  inserted  into 
the  orbicularis  oris;  therefore,  the  result  of  their  action  would  be  ap- 
parent at  the  point  of  insertion  or  in  the  region  of  the  anterior  teeth. 
All  of  the  muscles  of  expression  acting  normally  wall  maintain  normal 
occlusion  while  any  of  them  acting  abnormally  will  produce  malocclu- 
sion.   "When  we  consider  that  it  is  necessary  to  have  the  sum  total  of 


306  PRACTICAL    ORTHODONTIA 

the  muscles  of  expression,  levators  and  depressors  of  the  mandible,  in 
order  to  maintain  normal  occlusion,  and  that  any  group  of  any  muscle 
acting  abnormally  will  produce  malocclusion,  we  readily  see  what  a 
large  part  muscular  action  plays  in  retention. 

Normal  Approximal  Contact. — The  force  of  the  approximal  contact 
differs  from  the  force  of  the  inclined  plane  in  several  respects.  First, 
the  inclined  plane  of  the  tooth  acts  on  the  occluding  incline  of  the 
tooth  in  the  opposite  arch,  while  the  approximal  contact  acts  on  the 
adjoining  tooth  in  the  same  arch;  also,  the  inclined  plane  is  an  active 
force  while  the  approximal  contact  is  a  passive  force ;  that  is,  we  see 
the  result  or  the  lack  of  it  through  other  forces.  For  example,  we 
may  consider  the  blocks  of  stone  in  a  masonic  arch;  as  long  as  they 
are  in  their  proper  place  the  passive  force  that  they  exert  to  hold  up 
the  structure  above  them  is  great.  If  one  of  them  be  removed  or  dis- 
placed the  entire  arch  will  collapse  because  of  the  absence  of  the  force 
exerted  by  the  approximal  contact.  A  simpler  example  would  be  the 
staves  of  a  barrel.  Here  the  pressure  of  the  staves  is  balanced  by  the 
force  of  the  hoops.  Both  are  passive,  yet  if  one  stave  is  removed  or 
broken  the  entire  barrel  will  fall  to  pieces.  The  hoops  and  staves  of  a 
barrel  occupy  very  much  the  same  relation  to  each  other  that  the 
approximal  contact  of  the  teeth  and  the  muscular  pressure  bear  to  nor- 
mal occlusion. 

The  example  that  the  author  has  cited  above,  in  trying  to  show  what 
is  meant  in  regard  to  the  passive  force  of  the  approximal  contact  of  the 
teeth,  may  be  further  shown  with  billiard  balls,  or  any  spheres  of  the 
same  size.  As  the  approximal  contact  of  the  teeth  is  but  a  point,  the 
example  of  the  sphere  may  be  better.  If  you  take  three  spheres  and 
have  them  touching  each  other,  lying  in  a  straight  line,  you  will  be 
able  to  apply  great  pressure  from  the  opposite  sides  of  them  providing 
this  pressure  is  also  in  a  straight  line ;  the  spheres  will  occupy  the  same 
relative  position  and  will  not  move.  However,  if  you  deflect  the  line 
of  the  application  of  your  force  but  slightly,  one  or  all  of  the  spheres 
will  be  moved  from  the  position.  Likewise,  if  the  teeth  are  so  ar- 
ranged in  the  dental  arch  that  the  approximal  contact  points  are  nor- 
mal, each  tooth  will  remain  in  its  proper  position  and  the  proper  shape 
of  the  arch  will  be  maintained.  All  of  the  active  forces  that  are 
brought  to  bear  on  the  teeth  and  arches  will  be  resisted  by  the  passive 
force  of  the  approximal  contact  points  of  the  various  teeth.  Many 
cases  have  resulted  in  failure  when  all  other  things  were  as  nealy  nor- 
mal as  was  possible  under  the  circumstances.  A  position  that  needs 
watching  is  that  of  the  canines,  especially  the  mandibular  for  if  they 


RETENTION    OF    TEETH  307 

are  not  placed  so  that  the  approximal  contact  is  correct,  we  shall  soon 
find  them  slipping  out  of  place  and  the  entire  arch  collapsing,  as  a  re- 
sult of  which  the  normal  occlusion  will  soon  be  destroyed.  As  may  be 
imagined,  those  teeth  that  are  not  well  supported  by  the  inclined 
planes  require  a  greater  amount  of  watching  than  do  the  premolar  or 
molar  series.  This  brings  us  to  the  fact  that  there  is  a  definite  rela- 
tion existing  between  the  inclined  planes  and  the  width  of  the  ap- 
proximal contact. 

Normal  Cell  Metabolism. — If  the  cell  metabolism  is  normal,  we  shall 
have  the  proper  development  of  the  peridental  membrane  and  alveolar 
process.  It  is  evident  that  the  teeth  are  supported  by  the  above  named 
structures  and  in  the  majority  of  cases  the  alveolar  process  develops  to 
support  the  teeth  accordingly  as  the  forces  are  applied.  Of  course,  the 
peridental  membrane  is  that  "membrane  which  covers  the  root  of  the 
tooth  occlusally  to  the  enamel,  the  fibers  of  which  pass  from  the  cemen- 
tum  into  the  connective  tissue  supporting  the  epithelium,  into  the 
fibrous  mass  of  gum,  into  the  periosteum,  into  the  cementum  of  the  ad- 
joining tooth,  and  into  the  alveolar  wall."  This  shows  that  the  peri- 
dental membrane  not  only  supports  the  tooth  but  also  supports  the  soft 
tissue  around  the  tooth  and  some  of  its  cellular  elements  form  the  bone 
of  the  alveolar  Avail.  This  places  the  peridental  membrane  and  the 
cells  as  the  prime  factors  that  have  to  do  with  the  permanent  re- 
tention of  the  tooth.  If  all  of  the  other  forces  are  normal  the  periden 
tal  membrane  cells  will  do  their  part  and  a  normal  alveolus  will  re- 
sult and  the  tooth  will  be  permanently  retained.  Unfortunately  we 
often  find  conditions  that  arise  and  make  the  end  we  wish  to  obtain 
impossible — sometimes  the  result  of  conditions  that  we  cannot  govern 
and  at  other  times  the  result  of  our  carelessness.  Factors  that  we  can- 
not control  are  those  that  arise  in  eases  of  lowered  vitality,  especially 
rickets,  which  disturb  the  normal  cell  metabolism.  In  such  cases,  the 
bone  formed  will  be  of  such  faulty  structure  that  the  teeth  will  not 
remain  where  placed.  Those  that  Ave  can  govern  are  those  that  arise 
when  Ave  tamper  Avith  some  of  the  forces  mentioned,  or  when  Ave  so 
construct  our  retaining  appliance  that  the  natural  forces  cannot  do 
their  work.  One  of  the  most  common  mistakes  is  to  make  an  appliance 
so  that  the  teeth  will  be  held  rigid;  one  that  will  support  the  teeth  in 
every  direction  and  not  alloAV  any  of  the  force  of  mastication  to  fall 
on  the  teeth ;  constructing  mechanical  retainers  so  as  to  interfere  with 
the  proper  approximal  contact  of  the  teeth ;  or  holding  the  teeth  so 
that  the  influence  of  the  inclined  planes  becomes  inactive.  In  order 
that  the  peridental  membrane  may  perform  its  proper  function,  in 


308  PRACTICAL   ORTHODONTIA 

order  that  the  osteoblasts  may  deposit  and  build  bone  as  they  should, 
it  is  necessary  for  the  teeth  to  be  used  as  they  should.  In  other  words 
the  proper  force  must  be  brought  to  bear  on  the  teeth  at  all  times. 

Normal  Atmospheric  Pressure. — Another  force  that  is  difficult  to 
classify,  yet  one  that  must  be  taken  into  consideration  in  the  retention 
of  teeth,  is  the  force  of  the  atmosphere  in  respiration  and  deglutition. 
The  air  as  it  passes  through  the  nasal  cavity,  filling  all  of  the  sinuses 
as  it  does,  exerts  a  wonderful  pressure  in  the  course  of  a  year.  The 
pressure  may  be  slight  with  each  breath,  but  when  this  force  is  added 
or  subtracted,  during  the  growing  period  of  the  child's  life  a  great 
difference  will  be  noted.  Also,  with  each  act  of  swallowing  we  have  the 
pressure  of  the  tongue  and  lips  plus  the  pressure  of  the  air  as  a  factor 
that  plays  an  important  part  in  the  retention  of  teeth.  In  order  to 
get  the  advantage  of  the  forces  we  must  be  sure  that  we  have  a  normal 
nasal  tract  as  well  as  a  normal  occlusion.  Retention  will  be  a  failure 
unless  the  child  is  receiving  its  supply  of  oxygen  in  the  proper  manner. 

Summary  of  Forces  of  Retention 

In  summing  up  these  forces  of  retention,  the  author  wishes  to  im- 
press upon  the  readers  their  importance  as  grouped  together  in  certain 
cases.  Beginning  with  the  last  one,  normal  atmospheric  pressure,  we 
find  that  it  is  very  closely  associated  with  normal  muscular  pressure — 
so  closely  that  if  one  is  faulty  the  other  is  sure  to  be.  If  the  nasal  tracts 
are  closed  or  not  properly  developed,  abnormal  muscular  pressure  will 
result,  caused  by  abnormal  breathing.  In  case  of  enlarged  tonsils,  we 
see  the  evil  effect  of  long  enforced  voluntary  muscular  action,  as  the 
child  endeavors  to  relieve  the  pressure  and  render  breathing  freer.  It 
would  be  useless  to  expect  retention  to  be  a  success  as  long  as  this  ab- 
normal pressure  of  the  muscles  and  forced  mouth-breathing  are  con- 
tinued. Xo  matter  ho\v  long  mechanical  retention  is  employed,  failure 
would  be  the  final  result. 

As  the  cells  of  the  peridental  membrane  respond  to  any  force  that  is 
brought  to  bear  upon  the  teeth,  it  is  evident  that  any  of  the  forces  of 
occlusion  that  are  wrong  will  also  exert  some  evil  influence  upon  the 
cellular  elements,  and  the  development  of  the  tissue  will  be  faulty. 

Attention  has  already  been  called  to  the  length  of  the  overbite  as 
compared  with  the  length  of  the  buccal  cusps,  of  the  molars  and  pre- 
molars. In  the  normal  denture,  the  length  of  the  overbite  should  be 
the  same  as  the  length  of  the  buccal  cusps.  This  is  the  condition  as 
found  in  the  teeth  before  abrasion  and  wear  have  taken  place.    As  man 


RETENTION    OF    TEETH  309 

advances  in  age,  and  as  the  teeth  are  worn  down,  we  find  that  the  wear 
of  the  molars  and  premolars  corresponds  with  that  of  the  anterior 
teeth.  This  permits  the  "end-to-end"  bite  as  described  by  A.  H. 
Thompson.  It  also  accounts  for  the  mistakes  made  by  some  who 
thought,  because  they  found  this  end-to-end  bite,  that  we  had  no  nor- 
mal occlusion.  The  author  has  shown  that  the  teeth  are  retained  by 
the  inclined  plane  and  the  harmony  in  the  size  of  the  arches.  As  the 
cusp  and  the  overbite  are  worn  off,  it  is  plain  to  all  that  the  force  ex- 
erted by  the  inclined  plane  becomes  less  and  less.  The  harmony  in 
the  size  of  the  arches  is  maintained  and  the  approximal  contact  be- 
comes more  important.  In  fact,  as  the  influence  of  the  inclined  plane 
is  lost,  the  approximal  contact  becomes  more  important  until  it  is  ex- 
erting more  force  in  maintaining  normal  occlusion  than  the  inclined 
plane  exerts.  It  would  then  be  safe  to  say  that  the  teeth  are  guided 
and  held  in  place  in  early  life  by  the  inclined  plane.  When  the  dental 
apparatus  becomes  complete,  the  approximal  contact  becomes  an  im- 
portant factor  and  as  the  force  of  the  inclined  plane  is  lost,  it  (ap- 
proximal contact)  becomes  the  greatest  force  that  holds  the  teeth 
where  they  belong. 

As  the  length  of  the  cusp  decreases  the  width  of  the  approximal  con- 
tact increases.  This  change  can  be  followed  in  the  study  of  the  human 
denture  and  in  the  study  of  evolution.  In  a  well-formed  dental  appa- 
ratus— one  which  has  not  been  long  used — we  find  that  the  approximal 
contact  is  but  a  point ;  also  that  it  is  some  distance  from  the  occlusal 
surface  of  the  teeth.  As  the  cusps  and  cutting  edge  of  the  teeth  are 
worn  off,  the  occlusal  surface  becomes  near  the  approximal  contact  point 
until  finally  the  contact  point  is  close  to,  and  later  at,  the  occlusal  sur- 
face. After  the  teeth  become  worn  off  to  a  greater  extent,  the  contact 
point  is  reached ;  it  is  worn  down  and  a  greater  surface  of  the  teeth  is 
in  contact  than  was  the  case  early  in  life.  Instead  of  having  but  a  point 
in  contact,  we  have  a  surface.  When  the  teeth  have  been  in  a  position 
of  malocclusion  for  some  time,  the  approximal  contact  point  becomes 
worn  abnormally.  As  a  result  of  this,  it  becomes  extremely  difficult  to 
keep  them  in  their  proper  position.  That  is  why  it  has  been  found  so 
difficult  to  make  teeth,  which  have  occupied  positions  of  torsiversion, 
retain  their  proper  position  in  adults.  It  is  not  because  of  the  age  of 
the  patient  but  because  of  the  abnormal  approximal  contacts.  There- 
fore, the  relative  importance  of  the  inclined  plane  and  the  interproximal 
contact  as  a  factor  in  retention,  changes  during  the  lifetime  of  the  in- 
dividual. 

The  natural  forces  of  retention  must  alwavs  be  considered  in  the  con- 


310  PRACTICAL   ORTHODONTIA 

si  ruction  of  the  mechanical  retaining  appliance.  The  mechanical  device 
is  only  to  aid  nature  and  nothing  must  be  done  that  will  interfere  with 
the  forces  of  occlusion.  With  this  view  in  mind  we  will  pass  to  the 
consideration  of  mechanical  devices. 

Mechanical  Forces  of  Retention 

Simple  Passive  Intramaxillary  Retention. — The  first  form  of  me- 
chanical retention  used  was  simple  passive  intramaxillary.  In  this  form, 
we  take  advantage  of  some  tooth  that  has  not  been  moved  to  hold  a  tooth 
that  has  been  moved.  We  depend  upon  the  large  and  favorably  located 
teeth  to  retain  the  ones  that  have  been  moved.  It  does  not  require  much 
force  to  prevent  a  tooth  from  returning  to  its  old  position ;  therefore,  as 
a  rule,  the  retaining  appliance  can  be  made  very  simple.  It  may  be  a 
band  and  spur,  as  shown  in  Fig.  416.  In  making  use  of  the  band  and 
spur,  as  far  as  the  principle  is  concerned,  it  makes  no  difference  whether 
the  band  is  placed  on  the  tooth  that  has  been  moved  or  on  the  firm  tooth. 
The  advantage  of  this  form  of  retention  is  the  ease  with  which  it  can 
be  constructed.    Having  a  firm  tooth  as  a  base,  no  mechanical  construc- 


Fig.    416. — Simple   passive    intramaxillary    retention. 

tion  of  the  appliance  is  needed  to  assist  in  retention.  Simple  passive 
intramaxillary  retention  is  seldom  used,  for  in  most  cases  of  malocclu- 
sion it  becomes  necessary  to  move  so  many  teeth  that  there  are  none 
that  have  not  been  moved  that  can  be  utilized  as  the  base  for  retention. 

Simple  Compound  Intramaxillary  Retention. — Compound  retention 
of  this  variety  is  where  a  number  of  teeth  that  have  been  moved  are 
retained  by  one  or  more  teeth  that  have  not  moved.  This  is  the  style  of 
retention  used  in  cases  resulting  from  lip  habits,  where  the  superior  an- 
terior teeth  have  been  forced  outward  without  disturbing  the  canines. 
After  the  four  anterior  teeth  have  been  placed  in  their  proper  position, 
bands  are  placed  on  the  canines  with  a  wire  running  labial  to  the  inci- 
sors soldered  to  the  canine  bands,  which  will  prevent  the  superior  ante- 
rior teeth  from  again  retruding.  This  form  of  device  is  simple  com- 
pound intramaxillary  retention. 

In  some  cases,  where  there  is  a  great  tendency  for  the  corrected  tooth 
to  return  to  the  old  position,  the  retainer  is  made  in  such  a  manner  that 


RETENTION    OF    TEETH 


311 


it  will  exert  an  active  force.  This  is  accomplished  by  having  the  spur 
made  from  some  material  that  possesses  spring,  and  so  made  and  ad- 
justed that  a  spring  force  will  be  exerted  upon  the  malposed  tooth  to 
overcome  the  backward  tendency. 

Stationary  Intramaxillary  Retention  can  be  produced  but  is  not  de- 
sirable. In  those  cases  in  which  the  teeth  are  held  rigid,  it  has  been 
found  that  the  normal  cell  metabolism  is  interfered  with  to  such  an 
extent  that  the  teeth  do  not  become  firm.  Therefore,  every  effort  should 
be  made  to  allow  the  teeth  to  respond  to  the  forces  of  mastication  as  much 
as  possible. 

Reciprocal  Intramaxillary  Retention  is  used  in  those  cases  that  have 
been  regulated  with  reciprocal  anchorage.  It  is  the  pitting  of  the  back- 
ward tendency  of  one  tooth  that  has  been  moved  against  the  backward 
tendency  of  another  tooth  that  has  also  been  moved.    The  simplest  form 


Fig.    417. — Simple   primary    reciprocal   intramaxillary   retention. 

of  this  principle  is  shown  in  Fig.  417  where  two  central  incisors  have 
been  moved  toward  each  other.  By  passing  the  ligature  wire  around 
them,  one  is  made  to  retain  the  other.  This  is  primary  reciprocal  re- 
tention of  the  passive  variety — primary,  because  the  appliance  is  hold- 
ing only  the  teeth  to  which  it  is  attached;  passive,  because  there  is  no 
spring  or  pull  in  the  ligature,  which  only  occurs  as  the  teeth  try  to  re- 
turn to  their  old  position. 

Compound  Reciprocal  Retention  is  where  the  backward  tendency  of 
two  or  more  teeth  is  overcome  by  the  backward  tendency  of  two  or  more 


312  PRACTICAL   ORTHODONTIA 

other  teeth,  which  are  trying  to  return  in  an  opposite  direction.  Fur- 
thermore, the  appliance  is  so  constructed  that  it  is  attached  to  less  teeth 
than  the  number  that  are  being  retained.  With  this  form  of  appliance 
we  have  the  greatest  working  efficiency.  Compound  reciprocal  retention 
is  used  in  the  active  and  passive  form.  Compound  passive  reciprocal 
intramaxillary  retention  is  often  employed  in  retaining  the  six  anterior 
teeth.  An  example  is  shown  in  Fig.  -418,  in  which  the  six  anterior  teeth 
have  been  moved.  All  of  the  teeth  have  been  moved  from  positions  of 
lingual  occlusion.  By  placing  bands  on  the  canines  and  soldering  a 
wire  on  the  lingual  sides  of  the  bands  so  that  it  will  engage  the  lingual 
surface  of  the  incisors,  the  six  teeth  are  retained  by  the  one  appliance. 


Fig.    418. — Compound   reciprocal   intramaxillary    retention;    lingual    bar. 

The  lingual  tendency  of  the  canines  is  overcome  by  each  other  and  the 
backward  tendency  of  the  incisors  is  also  overcome  by  the  same  appli- 
ance, which  justifies  the  use  of  the  term  compound  reciprocal  intramax- 
illary retention.  As  there  is  no  spring  to  the  appliance,  it  only  exerts 
force  as  the  teeth  try  to  return,  being  called  passive  retention.  This 
principle  can  be  carried  further,  and  by  placing  bands  on  the  molars 
and  canines  and  soldering  a  wire  on  the  lingual  side  of  these  bands,  the 
retainer  can  be  made  to  retain  all  of  the  teeth  in  the  arch,  if  they  have 
all  been  in  lingual  occlusion. 

In  using  the  lingual  retainer  just  described  on  all  of  the  teeth  in  one 
arch,  it  has  been  found  that  the  force  of  the  teeth  may  be  greater  than 
the  passive  force  exerted  by  the  appliance.    As  a  result,  the  arch  would 


RETENTION    OF    TEETH  313 

contract  and  the  teetli  would  assume  a  position  of  malocclusion,  much 
to  the  chagrin  of  the  operator.  To  avoid  this,  active  compound  recip- 
rocal intramaxillary  retention  was  devised,  which  consists  in  making 
the  lingual  retaining  wire  out  of  some  material  that  has  a  spring,  and 
which  is  so  constructed  that  the  pressure  of  the  spring  can  be  regulated. 
If  the  teeth  are  exerting  more  force  than  is  exerted  by  the  retaining 
wire,  the  wire  is  removed  from  the  small  open  tubes  holding  it  in  place 
and  more  spring  given  to  the  lingual  wire,  which  makes  the  appliance 
of  sufficient  strength  to  hold  the  teeth  (Fig.  410).  By  making  an  ap- 
pliance of  this  kind  we  are  able  to  have  one  of  smaller  bulk  and  have 
absolute  control  over  the  teeth  at  all  times.     There  are  other  forms  of 


Fig.   419. — Simple  compound  reciprocal  intramaxillary   retention,   with   removable  lingual  bar. 

retaining  devices  that  utilize  this  principle,  which  are  fully  described 
in  the  chapter  on  treatment. 

Intermaxillary  Retention  is  where  the  force  necessary  to  overcome 
the  backward  tendency  of  the  teeth  in  one  arch  is  derived  from  some 
teeth  in  the  opposite  arch.  This  form  is  primary  and  compound,  active 
and  passive,  also  simple  and  stationary.  Primary  passive  intermaxillary 
retention  is  where  the  backward  tendency  of  one  tooth  in  one  arch  is 
overcome  by  a  tooth  in  the  other.  The  most  common  form  of  this  re- 
tention is  when  the  loss  of  the  maxillary  second  deciduous  molar  makes  it 
necessary  to  hold  the  maxillary  first  molar  distally.  This  form  of  reten- 
tion can  be  taken  advantage  of  by  cementing  a  pin  on  the  occlusal  sur- 
face of  the  mandibular  second  deciduous  molar  so  as  to  engage  the  mesio- 
occlusal  surface  of  the  maxillary  first  molar.  The  favorable  location  of 
one  tooth  to  the  other  makes  possible  this  form  of  retention. 


314  PRACTICAL    ORTHODONTIA 

Active  Primary  Intermaxillary  Retention  is  where  the  force  neces- 
sary to  overcome  the  backward  tendency  of  a  tooth  in  one  arch  is  ob- 
tained from  a  tooth  in  the  opposite  arch.  An  example  of  this  is  shown 
in  Fig.  420  in  which  a  canine,  which  was  in  infra-occlusion,  has  been 
brought  to  the  proper  position.  In  order  to  retain  it  there  a  rubber 
band  is  attached  to  the  mandibular  first  premolar. 

Reciprocal  Intermaxillary  Retention  is  where  the  backward  tendency 
of  the  teeth  in  one  arch  is  overcome  by  the  backward  tendency  of  the 


Fig.    420. — Retention    of   superior   canine,    which    was   moved    from    infra-occlusion    retained    by 
rubber   band    from   lower  premolar,    which   makes   active   primary    simple    intermaxillary    retention. 


teeth  in  the  opposite  arch.     This  may  be  primary  or  compound,  but  in 
most  cases  is  compound.     It  may  be  used  either  active  or  passive. 

Passive  Reciprocal  Simple  Intermaxillary  Retention  is  where  the 
backward  tendency  of  the  teeth  in  one  arch  is  overcome  by  the  back- 
ward tendency  of  the  teeth  in  the  other  arch,  the  appliance  being  so 
constructed  and  attached  that  the  teeth  will  be  tipped  if  sufficient  force 
is  exerted  upon  the  appliance.  The  appliance  is  made  so  that  it  exerts 
force  upon  the  teeth  only  as  they  try  to  return  to  their  old  positions. 
Should  the  appliance  become  bent  or  the  teeth  slip  slightly,  no  force 
will  be  exerted,  which  will  regain  what  has  been  lost.  Passive  inter- 
maxillary retention  has  been  used  for  some  time  in  the  retention  of 
distoclusion  with  labioversion  of  maxillary  anterior  teeth  or  Class  II, 
Division  1  cases,  or  in  fact  in  any  class  of  cases  in  which  the  mesio- 
distal  relation  of  the  teeth  has  been  changed. 


RETENTION   OF    TEETH 


315 


Plane  and  Spur  Retention. — A  form  that  was  much  used  was  de- 
scribed by  Angle  and  has  been  known  as  the  "plane  and  spur."  It 
consists  of  a  band  fitted  to  an  upper  and  lower  tooth,  generally  to  the 


Fig.    421. — Plane   and   spur,   which   is   passive   reciprocal   intermaxillary    retention.      (Angle.) 

first  molars,  which  have  been  chosen  on  account  of  their  size  and 
strength.  A  plane  is  soldered  on  the  buccal  surface  of  the  upper  band 
(Fig.  421)  and  a  spur  on  the  buccal  surface  of  the  lower  band  for  the 
purpose,  in  distoclusion  or  Class  II,  of  engaging  the  anterior  part  of  the 
plane  on  the  upper  molar  band.  This  retainer  antagonizes  the  back- 
ward tendency  of  the  teeth,  but  the  disadvantages  lie  in  its  principle : 


Upper  molar 

.Clamp  band 
with  plane 

^■--Clamp  band 
with  spur 

Lower  1st.  molar 

Fig.  422. — Shows  how  force  of  passive  retention  in  Class  II  tends  to  tip  upper  and  lower  molars. 


First,  it  depends  only  upon  the  firm  location  of  the  molar  teeth  to  sup- 
ply the  resistance  necessary  to  prevent  the  backward  tendency  of  the 
teeth;  second,  there  is  no  attachment  or  construction  of  the  appliance 
that  will  give  the  teeth  any  assistance;  and,  third,  the  force  is  entirely 
passive,  that  is,  if  the  teeth  drop  backward  the  least  bit,  there  is  no 
way  of  regaining  the  movement  lost.  It  very  often  happens  that  the 
teeth  to  which  this  appliance  is  attached  will  be  tipped,  as  shown  in 
Fig.  422.  This  allows  the  teeth  mesial  and  distal  to  the  ones  to  which 
the  appliance  is  attached  to  assume  incorrect  positions.    Many  different 


316  PRACTICAL    ORTHODONTIA 

forms  of  the  plane  and  spur  have  been  used  and  attached  to  different 
teeth,  but  the  principle  has  always  remained  the  same. 

Passive  Reciprocal  Stationary  Intermaxillary  Retention  is  that  form 
in  which  the  teeth  in  one  arch  are  made  to  overcome  the  backward  ten- 
dency of  the  teeth  in  the  other,  the  appliance  being  so  attached  that  the 
teeth  supporting  it  cannot  tip  at  all.  Figs.  423  and  424  illustrate  very 
clearly  what  was  intended  to  be  done,  but  the  great  disadvantage  was 
that  it  held  the  teeth  too  firm  and  for  that  reason  this  form  of  retention 
was  used  by  the  author  onlv  on  one  case. 


Fig.    423.  Fig.    424. 

Figs.    423    and   424. — Showing   passive   reciprocal    stationary    intermaxillary    retention,    which    is    a 
very   unsatisfactory   form   to   use. 

Active  Primary  Reciprocal  Intermaxillary  Retention  is  where  the 
force  necessary  to  retain  the  teeth  that  have  been  moved  in  one  arch  is 
derived  from  the  teeth  that  have  been  moved  in  the  opposite  arch,  and  is 
of  an  active  nature.  Various  forms  of  this  principle  are  employed — e.  g., 
primary,  when  a  tooth  in  one  arch  is  used  to  retain  a  tooth  in  another 
arch.  This  form  is  used  when  a  canine  in  the  upper  arch,  which  has 
been  moved  from  mtra-oeclusion,  is  used  to  retain  a  lower  tooth  moved 
from  the  same  position,  by  placing  a  band  on  both  teeth  and  connecting 
them  by  means  of  a  light  rubber  ligature.  Fig.  425  illustrates  such  a 
condition. 

Active  Compound  Reciprocal  Intermaxillary  Retention  is  used  when 
the  teeth  of  one  arch  are  made  to  retain  the  teeth  in  the  opposite  arch, 
the  teeth  in  both  arches  having  been  moved.  This  is  the  form  of  reten- 
tion used  in  the  retaining  of  cases  caused  by  tongue  habits.     The  use 


RETENTION    OF    TEETH 


317 


of  the  rubber  ligature  that  supplies  the  active  force  causes  a  better  re- 
tention than  the  use  of  any  other  appliance. 

Compound  active  reciprocal  intermaxillary  retention  is  most  useful 
in  the  retention  of  Class  II,  or  distoclusion,  and  Class  III,  or  mesio- 
clusion, cases.  One  form  is  shown  in  Fig.  426.  The  details  of  construc- 
tion are  discussed  in  the  chapter  on  treatment  of  Class  II,  or  distoclu- 
sion, and  Class  III,  or  mesioclusion,  cases.    The  chief  advantages  of  this 


Fig.    425. — Active   primary    reciprocal    intermaxillary    retention    used    to    retain    canines    that   have 

been  in  infraversion. 

form  of  retention  are  that  it  prevents  the  tipping  of  the  molars  and  can 
be  so  adjusted  as  to  aid  the  settling  of  the  inclined  planes  of  the  teeth. 
The  use  of  this  form  of  retention  has  displaced  all  others  in  the  author's 
practice  for  Class  II,  or  distoclusion,  and  III,  or  mesioclusion,  cases. 
It  will  be  considered  further  in  the  treatment  of  cases. 


Upper  1st.  molar 


clamp 
band 

Spur  tor  rubber 
on  Lower  1st.  molar 

Fig.    426. — Compound    active    reciprocal    intermaxillary    retention    used    in    Class    II,    Division    I 

cases.       (See  also  Fig.  643.) 


Extramaxillary  Retention  is  that  form  in  which  the  force  necessary 
to  retain  the  teeth  is  derived  from  some  source  external  to  the  oral 
cavity.  It  is  derived  from  the  occipital,  cervical  or  facial  region  and  is 
very  little  used.  The  author  has  never  had  occasion  to  make  use  of  any 
of  these  forms. 


CHAPTER  IX 
IMPRESSIONS  AND  MODELS 

Preliminary  Consideration  of  Cases. — One  of  the  essential  things  in 
the  treatment  of  cases  is  a  thorough  understanding  of  the  conditions. 
The  case  must  be  studied  with  the  object  in  view  of  learning  the  cause 
of  the  malocclusion.  The  history  of  the  case  should  be  gone  into  in  order 
to  learn  whether  nasal  obstructions,  constitutional  conditions  or  habits 
have  played  a  prominent  part  in  the  production  of  the  malocclusions. 
Very  little  should  be  said  in  regard  to  the  prognosis  of  the  case  until 
after  the  condition  has  been  studied  from  models  made  from  good  im- 
pressions. 

It  is  very  necessary  that  an  orthodontist  should  be  able  to  take  the  im- 
pression skillfully  and  without  annoying  or  agitating  the  patient.  Many 
patients  have  been  frightened  away  from  the  operator  because  of  the 
crude  manner  in  which  he  obtained  the  impression. 

Taking  the  Impression. — In  order  that  we  may  obtain  the  best  im- 
pression possible — for  without  a  good  impression  we  cannot  have  a 
good  model — plaster  must  be  used.  The  advantages  of  plaster  are  so 
apparent  that  it  is  hardly  necessary  to  mention  them  here.  It  is  the  only 
material  that  will  give  an  accurate  reproduction  of  the  condition  as  it 
exists.  The  more  pronounced  the  malocclusion  the  greater  the  need 
of  plaster.  In  the  hands  of  the  skilled  operator  it  is  no  more  objection- 
able to  the  patient  than  modeling  compound.  Modeling  compound  has 
a  place  in  dentistry,  but  not  in  orthodontia,  for  the  making  of  record 
models.  Modeling  compound  impressions  can  be  used  for  study  models 
and  for  models  to  be  used  in  the  construction  of  appliances,  lingual 
arches  and  retainers.  The  teeth  should  be  carefully  cleaned,  and  the 
mucus  removed  from  the  teeth  and  gums  as  thoroughly  as  possible.  A 
tray  larger  than  the  dental  arch  should  be  selected,  being  perfectly 
smooth  on  the  inside  and  having  high  walls,  as  shown  in  Fig.  427.  One 
with  a  quarter  of  an  inch  between  the  teeth,  alveolar  process  and  the 
edge  of  the  tray  is  preferable.  The  tray  should  be  of  a  material  that 
will  permit  bending  so  that  it  can  be  shaped  to  the  dental  arch.  The 
tray  must  be  placed  in  the  mouth  and  the  cheeks  and  lips  pulled  over 
it,  which  enables  the  operator  to  observe  how  it  fits  and  the  patient  to 
become  familiar  with  the  sensation.     If  the  patient  has  a  tendency  to  . 

318 


IMPRESSIONS    AND    MODELS  319 

gag  or  is  frightened,  the  impression  must  not  be  taken  until  all  fear  is 
allayed,  and  a  tray  should  be  selected  that  will  not  produce  nausea. 

When  about  to  take  the  impression,  the  patient  is  carefully  protected 
with  a  suitable  towel  or  large  apron.     It  is  unnecessary  to  distribute 


Fig.   427. — Plaster  Irays. 

debris  of  plaster  upon  the  clothes  of  the  patient,  or  to  allow  it  to  ac- 
cumulate upon  the  floor  of  the  operating  room.  All  that  is  needed  is  an 
ordinary  towel  with  the  corners  pinned  up  to  make  a  pocket  into  which 
the  excess  pieces  of  plaster  are  dropped  when  the  impression  is  being 
taken. 


320  PRACTICAL    ORTHODONTIA 

A  quick-setting  plaster  should  be  chosen  so  that  it  will  not  be  neces- 
sary to  keep  the  material  in  the  patient's  mouth  very  long.  A  small 
plaster  bowl  (Fig.  428)  holding  the  required  amount  of  water  is  used, 
and  the  use  of  salt  depends  upon  the  rapidity  with  which  the  plaster 
sets  and  the  ability  of  the  operator  to  work  rapidly. 

The  plaster  is  slowly  sifted  into  the  water  until  the  water  will  take 
no  more  plaster.  Then  it  is  carefully  removed  from  the  bowl  and  placed 
in  the  tray,  as  shown  in  Fig.  429.  A  liberal  amount  of  plaster  should 
be  inserted  around  the  buccal  and  labial  parts  of  the  tray,  but  none 
should  be  placed  in  the  palatal  part.  The  tray  is  placed  in  the  mouth 
and  the  part  of  plaster  that  has  been  placed  on  the  labial  part  and  handle 
of  the  tray,  is  carefully  worked  under  the  lip  find  cheek.  This  is  done  to 
be  certain  that  no  air  is  caught  between  the  lip  and  impression.  After 
the  plaster  has  been  placed  under  the  lip,  care  must  be  taken  that  the 
impression  tray  is  in  the  proper  position — not  too  far  distally  or  mesi- 


Fig.   428. — Plaster  bowl,   which  must  be  smooth  inside,   so  that   hard  plaster  can  be  removed. 

ally,  nor  too  far  to  the  buccal,  and  straight  with  the  median  line  of  the 
face.  If,  in  forcing  the  upper  tray  into  place,  some  of  the  plaster  is 
forced  over  the  palatal  part  of  the  tray,  it  should  be  removed  at  once 
with  a  mouth  mirror.  In  taking  the  lower  impression,  just  before  the 
tray  is  forced  down  and  after  the  plaster  has  been  placed  under  the  lip, 
the  patient  should  be  instructed  to  raise  the  tongue,  and  while  the  tongue 
is  raised,  the  tray  is  forced  down.  This  insures  a  good  impression  of 
the  lingual  part  of  the  mouth.  Also,  the  fingers  should  be  passed  back 
to'  the  disto-buccal  part  of  the  tray  and  the  cheek  forced  buccally ;  for 
often  the  cheek  is  caught  under  the  heel  of  the  impression  tray,  thus 
spoiling  the  accuracy  of  the  impression. 


IMPRESSIONS    AND    MODELS 


321 


322  PRACTICAL    ORTHODONTIA 

The  tray  is  held  firmly  until  the  plaster  begins  to  set  and  then  pieces 
of  cotton  or  bibulous  paper  can  be  used  to  wipe  the  saliva  out  of  the 
mouth  and  to  remove  the  loose  pieces  of  plaster.  After  the  plaster 
is  hard  enough  to  hold  the  tray  in  place,  the  part  of  plaster  on  the 
outside  of  the  tray  is  removed.  Any  part  that  breaks  off  below  the 
border  of  the  tray  should  be  saved,  others  are  thrown  into  the  pocket 
made  by  pinning-  the  towel  at  the  corners.  After  all  pieces  of  the 
plaster  have  been  broken  away  from  the  tray,  the  tray  is  then  re- 
moved, leaving  the  impression  intact  in  the  mouth.  With  a  sharp 
knife,  using  a  chisel  stroke,  grooves  should  be  made  in  the  impres- 
sion over  the  canine  eminences,  as  that  is  the  most  convenient  way 
to  break  the  impression.  These  grooves  should  be  made  narrow  with 
straight  walls,  as  the  straight  walls  are  necessary  to  use  as  a  fulcrum 
for  the  knife  blade  in  breaking  away  the  plaster.  The  positions  of 
the  teeth  should  be  fixed  in  mind,  and  the  lip  pulled  out  of  the  way 
so  as  to  get  an  idea  of  the  anatomy  of  the  parts,  and  the  grooves  cut 
through  the  plaster  only  far  enough  to  permit  it  to  break.  The  blade 
of  the  knife  is  placed  in  the  groove  and  one  piece  is  pried  out.  Whether 
the  center  piece  or  the  side  pieces  are  broken  away  first  depends  upon 
the  position  of  the  teeth.  In  breaking  the  buccal  parts  away,  the  thumb 
should  be  placed  against  the  anterior  end  of  the  broken  plaster  and  the 
finger  placed  along  the  buccal  side  of  the  same  so  as  to  protect  the 
cheek.  After  the  buccal  and  labial  parts  have  been  removed,  the  pala- 
tal part  is  then  taken  out.  Occasionally  an  upper  impression  can  be 
taken  out  in  three  or  four  pieces,  but  a  greater  number  would  not  spoil 
the  value  of  the  impression.  In  removing  the  lower,  the  same  pro- 
cedure is  followed.  The  lingual  part  is  broken  as  near  the  median 
line  as  possible  by  pushing  lingually  on  one  side  of  it  from  about  the 
region  of  the  first  molar.  In  removing  the  pieces,  those  from  the  right 
side  should  be  laid  on  the  right  side  of  a  blotter  or  piece  of  clean  paper 
and  those  from  the  left  side,  on  the  left  side  of  the  blotter,  and  all  the 
other  pieces  placed  in  their  respective  relations  on  the  paper.  The  pieces 
of  the  impression  must  be  laid  away  until  they  are  dry  and  then  placed 
together  and  held  by  sticky  wax.  In  putting  these  impressions  together, 
the  small  pieces  of  the  right  side  must  be  stuck  to  the  large  pieces  of  the 
right  side,  and  so  on,  and  then  the  right  and  left  parts  of  the  impression 
put  together.  If  trouble  is  encountered  in  getting  the  halves  of  the  im- 
pression to  stay  together,  they  can  be  braced  by  sticking  a  match  across 
the  back  with  sticky  wax.  Figs.  430  and  431  show  the  upper  and  lower 
impressions  as  they  are  removed  from  the  mouth.  Fig.  432  shows  the 
appearance  of  the  upper  and  lower  after  they  are  put  together. 


IMPRESSIONS    AND    MODELS 


323 


Varnishing*  the  Impression. — The  impression  is  then  coated  with  a 
separating-  medium.  The  author  has  obtained  the  best  results  from 
the  use  of  shellac  and  sandarac  varnishes,  as  recommended  by  Angle. 
The  consistency  of  the  varnishes  can  be  learned  only  from  experience. 


Fig.  430. 


Fig.   431. 

Figs.  430  and   431. — Impressions  removed   from   mouth,   345,   upper  impression;   346, 

iovver    impression. 


Fig.   432. — Impressions   put  together  with   sticky   wax. 


Alcohol  must  be  added  to  the  varnishes  from  time  to  time  to  keep 
them  thin  enough.  One  coat  of  shellac  is  placed  on  the  impression 
with  a  fine  brush  from  a  solution  so  thin  that  all  of  the  shellac  will 
soak  into  the  impression.    If  this  first  application  leaves  a  coating  on 


324  PRACTICAL   ORTHODONTIA 

the  impression,  the  varnish  is  too  thick  and  the  impression  will  not 
produce  a  good  model.  The  object  of  this  coat  is  to  fill  all  of  the 
pores  in  the  impression,  color  the  impression  for  a  certain  distance, 
and  act  as  a  filler  for  the  next  coat.  The  second  coat  is  applied  only 
after  the  first  is  thoroughly  dry,  and  at  least  three  hours  should 
elapse  after  the  first  coat  is  put  on  before  the  second  is  applied.  This 
second  coat  should  cover  the  entire  surface  of  the  impression,  and  is 
taken  from  the  same  bottle  as  the  first.  The  purpose  of  the  second 
coat  of  shellac  is  to  fix  a  gloss  on  the  impression.  After  this  second 
coat  it  would  be  possible  to  separate  the  impression  from  the  model, 
if  it  was  poured  then.     However,  in  order  that  the  teeth  may  have  a 


Fig.  433. — Impression  poured  before  being  turned  over  on  glass  slab. 

better  gloss  and  that  the  impression  may  be  separated  more  readily, 
a  coat  of  very  thin  sandarac  is  placed  in  the  impression  of  the  teeth 
and  the  rough  parts  of  the  impression.  Care  must  be  taken  not  to 
get  any  of  the  sandarac  on  the  gingival  margins  of  the  teeth.  After 
the  last  coat  of  varnish  is  dry,  the  impression  is  ready  to  pour. 

Pouring-  the  Model. — The  plaster  used  for  the  model  should  be  one 
that  will  be  reasonably  hard  and  must  not  set  too  slowly.  The  plaster 
is  carefully  sifted  into  the  water  so  as  to  avoid  bubbles.  When  the 
water  has  taken  up  all  of  the  plaster,  the  mixture  is  placed  in  the  im- 
pression of  the  teeth  with  a  fine  brush.  In  filling  the  impression,  be- 
gin at  one  side  at  the  last  tooth  or  heel  and  fill  from  there  entirely 


IMPRESSIONS    AND    MODELS 


325 


around  the  impression.  The  plaster  is  carefully  placed  in  the  teeth 
so  as  to  expel  any  air  bubbles  that  may  occur  in  their  cusps.  After 
the  teeth  have  been  filled  with  the  brush,  the  remaining  part  of  the 
impression  can  be   filled   with   the   spatula,   and   a  large   amount   of 


pig-    434, — Impression    turned    over   and   placed    on   glass   slab. 


Fig.   435. — Impression   removed   from   glass   slab,   showing   square   corners. 


plaster  should  be  placed  on  the  impression,  as  shown  in  Fig.  433.  By 
this  time,  the  plaster  should  be  hard  enough  to  support  the  weight 
of  the  impression  and  also  stiff  enough  so  that  it  will  not  run  out  when 
turned  upside  down.     The  impression  is  now  turned  upside  down  on 


326  PRACTICAL    ORTHODONTIA 

the  glass  slab,  as  shown  in  Fig.  434,  and  the  plaster  pulled  up  around 
the  impression.  The  disto-buccal  corners  of  the  plaster  must  be  left 
square,  as  shown  in  Fig.  435,  for  the  reason  that  they  represent  the 
corners  of  the  finished  model. 

Separating  the  Model. — After  the  plaster  has  become  hard  the  im- 
pression   can    then    be    separated    from    the    model.     The    plaster    is 


Fig.    436. — Plaster    trimmed   away    from    border    of   impression    previous    to    separation. 


Fig.    437. — Occlusal   surface    of   impression   trimmed    to    show    discoloration    from    shellac    varnish. 

trimmed  away  from  the  edge  of  the  impression  until  the  border  can 
be  seen  plainly.  Fig.  436  shows  the  preliminary  trimming  and  Fig. 
437  the  manner  of  trimming  the  occlusal  portion  until  the  stain  of  the 
shellac  can  be  seen.    A  groove  is  then  cut  into  the  impression  as  near 


IMPRESSIONS    AND    MODELS 


327 


the  gingival  portion  of  the  teeth  as  possible  so  that  it  will  extend 
from  the  right  distal  corner  to  the  left  distal  corner  (Fig.  438).  Then 
grooves  are  cut  parallel  to  the  long  axis  of  the  teeth  and  at  right 


Fig.   438. — Grooves  cut   into   impression   before  separation. 

angles  to  the  first  groove.  These  grooves  are  carefully  cut  into  the 
impression  until  the  stain  from  the  shellac  shows.  The  pieces  are 
then  pried  off  by  prying  toward  the  occlusal  surface.  No  piece  of 
impression  larger  than  a  tooth  should  be  removed  at  one  time.  When 
prying  off  the  impression,  care  must  be  taken  not  to  break  off*  the 
teeth. 


Fig.  439. — A  to  C  represents  height  of  model;  A  to   B,  the  anatomical  portion  of  model;   C  to 
B   equals   one-third   of   distance   from   A  to   B;   A   to   B   equals   three-fourths   of   height   of   mode!. 


Trimming'  the  Model. — After  the  impression  is  removed,  the  model 
is  then  ready  to  be  trimmed.  The  part  of  the  model  representing  the 
teeth  and  alveolar  process  is  known  as  the  anatomic  portion.     The 


328 


PRACTICAL    ORTHODONTIA 


rest  of  the  model  is  known  as  the  base  or  art  portion.    In  handling  the 
model,  the  anatomic  portion  should  not  be  touched  with  the  fingers. 


Fig.    440. — A    group   of   instruments    used   in   trimming   the   model. 


IMPRESSIONS    AND    MODELS 


329 


The  anatomic  portion  of  the  model  is  measured  in  the  highest 
part  and  that  length  represents  three-fourths  of  the  height  of  the 
completed  model.  Therefore,  the  art  portion  of  the  model  is  one- 
third   of  the  height   of  the   anatomic   portion.       These  measurements 


4# 

Fig.    441. — Plaster   plane,   used   in   trimming   the    model. 


Fig.   442. — Taking  measurement  from  the  median  line  to  a  point   distal  to  the   molars. 


can  better  be  understood  by  referring  to  Fig.  439.  After  these  meas- 
urements have  been  obtained,  the  art  portion  of  the  model  is  marked  on 
all  sides  and  then  the  base  is  trimmed  to  the  line.     The  lower  model 


:;:;n 


PRACTICAL    ( WTIIODONTIA 


should  always  be  trimmed  first.     The  base  should  be  finished  smooth 
before  any  side  is  trimmed. 


Fig.    443. — Model  with  base  and  back  trimmed.      Back  must  be  at  right  angles  to  base. 


Fig.   444. — Sides  trimmed  at   right  angles   to   base. 


In  order  to  properly  trim  the  art  portion  of  the  model,  it  is  neces- 
sary to  have  a  small  square,  a  pair  of  compasses,  one  or  two  sharp 


IMPRESSIONS    AND    MODELS  331 

strong  knives  (Fig.  440),  and  a  plaster  plane  (Fig.  441).  The  plane 
will  be  found  very  difficult  to  manipulate  at  first  but  when  used  prop- 
erly it  gives  a  finish  that  can  be  obtained  in  no  other  way. 

After  the  base  has  been   trimmed  and  finished   with  the   plane,   a 


Fig.    445. — Appearance    of   base    of   model    after    the  anterior   corners    have    been    established    and 
the  front  marked  with  compasses. 


Fig.   446. — Distal  corners  of  model   trimmed  at  right  angles  to   mesial  corners. 

measurement  is  taken  from  the  median  line  to  a  point  distal  to  the 
molars  (Fig.  442).  This  point  distal  to  the  molar  establishes  the  dis- 
tal portion  of  the  art  portion  of  the  model.  It  is  trimmed  straight 
across  and  at  right  angles  to  the  base  (Fig.  443).  The  sides  are  then 
trimmed  and  form  a  straight  line  parallel  with  the  lines  of  occlusion 


332 


PRACTICAL   ORTHODONTIA 


from  the  molars  to  the  canine,  being  trimmed  only  close  enough  to 
the  anatomy  to  get  all  of  the  overhanging  edges  (Fig.  444).  Care 
must  be  taken  to  hold  the  knife  at  right  angles  to  the  base,  for  the 
side  must  be  trimmed  at  right  angles  to  the  base.  Very  often  the 
sides  are  trimmed  so  close  to  the  anatomic  portion  as  to  ruin  some 


Fig.  447. — A,  B,  C  are  points  on  the  arc  of  circle,  the  radius  of  which  is  the  distance  from 
A  to  C.  F,  G,  H  are  points  on  circle,  the  radius  of  which  is  the  distance  from  A  to  C.  El  to 
E2  and  Dl  to  D2  are  trimmed  at  right  angles  to  lines  running  from  C  to  E  and  A  to  D,  which 
are  one-fourth  of  distance  A,  B,  C.  The  arc  H,  G,  F  is  centrally  located  between  D2  and  E2. 
The  different  parts  of  the  model  should  be  trimmed  in  the  following  order:  (1)  The  base;  (2) 
the  back  from  D  to  F;  (3)  the  sides  A  to  F  and  C  to  D;  (4)  the  front  A,  B,  C;  (5)  the  corners 
Dl,  D2  and  El,  E2;    (6)  the  arc  F,  G,  H. 


of  the  anatomy  and  greatly  mar  the  beauty  of  the  model.  The  an- 
terior part  of  the  model  is  now  trimmed.  A  mark  is  made  on  the  side 
in  the  region  of  the  canine  to  represent  the  corners,  as  shown  in  Fig. 
445.  After  these  corners  are  established,  the  compasses  are  placed  on 
each  mark  and  the  distance  between  the  two  points  represents  the 
radius  of  a  circle.     The   anterior  part  of  the  lower  model  is  then 


IMPRESSIONS    AND    MODELS 


333 


trimmed  to  represent  the  arc  of  a  circle,  the  radius  of  which  is  the 
distance  from  one  canine  point  to  the  other.  Then  the  distal  corners 
of  the  model  are  trimmed  at  right  angles  to  a  line  passing  from  the 


Fig.    448— Base   of   completed  lower   model.      Front   trimmed   round. 


Fig.   449.— Base   of  completed  upper  model.     Front  trimmed   to   a   point. 

canine  point  to  the  opposite  distal  point  (Fig.  446).  The  distal  cor- 
ners are  trimmed  so  as  to  be  one-fourth  the  length  of  the  arc  of  the 
circle  that  forms  the  front  of  the  art  portion  of  the  lower  model 


:::;! 


PRACTICAL    ORTHODONTIA 


(Fig-.  447).  The  distal  part  of  the  base  of  model  is  divided  into 
fourths,  and  two-fourths  are  used  in  making  a  curve  as  shown  in 
Pigs.  447  and  448.  This  distal  curve  represents  the  arc  of  the  circle, 
the  radius  of  which  is  the  distance  from  one  canine  point  to  the  other. 
The  curve  in  the  front  and  the  curve  in  the  back  are  then  arcs  of 
circles  that  have  the  same  radius.  The  base  of  the  model  then  ap- 
pears as  shown  in  Figs.  447  and  448.     Fig.  441)  illustrates  the  base  of 


Fig.  4H0. — Method  of  obtaining  the  measurements  for  the  anatomic  and  art  portions  of  the 
upper  model.  Measure  the  anatomic  portion  of  upper  model,  which  is  three-fourths  of  height  of 
completed  model.  Then  add  one-third  of  distance  from  A  to  I!,  set  square  and  make  mark  at  C. 
Place  upper  model  on  lower  model  and  measure  from  C  on  upper  to  C  on  lower,  with  teeth  in 
occlusion.     Make  a  scratch  all  around  upper  model  with  square,  as  shown  by  dotted  line. 


an  upper  model,  which  is  trimmed  as  follows:  The  anatomic  por- 
tion is  measured  in  the  same  manner  as  described  above,  and  the 
height  of  the  art  portion  established  in  the  region  of  the  median  line. 
The  anatomic  and  art  portions  of  the  upper  model  are  obtained  as 
shown  in  Fig.  450.  Upon  the  upper  model  a  line  is  circumscribed 
around  its  entire  circumference,  and  the  base  is  then  trimmed.  The 
distal  line  and  sides  are  obtained  in  the  same  manner  as  in  the  lower 
model.  The  canine  points  are  then  fixed  but  the  front  of  the  upper 
model  is  made  pointed,  as  shown  in  Fig.  450.  The  anterior  angle  is  a 
point  on  the  arc  of  a  circle,  the  radius  of  which  is  the  distance  be- 


IMPRESSIONS    AND    MODELS 


335 


tween  the  canine  points.  The  distal  comers  are  trimmed  the  same  as 
they  were  in  the  lower,  except  that  they  are  made  one-third  of  the 
length  of  the  line  from  the  canine  point  to  the  center  of  the  model. 
The  distal  curve  is  obtained  in  the  same  manner. 

Models  when  trimmed  this  way  are  well  balanced,  and  if  care  has 
been  exercised  all  through  the  procedure,  there  is  no  necessity  to 
apologize  for  their  appearance. 

Modeling-  Compound  to  Study  Models. — Study  models  can  be  made 
from  modeling  compound  impressions  at  any  time  during  the  treat- 
ment of  the  case.  They  are  made  for  the  purpose  of  comparing  the 
progress  of  treatment  with  the  original  model  made  at  the  beginning 
of  the  case.     They  can  be  made  by  taking  an  impression  of  the  teeth, 


Fig.     451.— Modeling    compound    shaped     for      Fig.    452— Modeling    compound    impression    for 
the    taking    of    impression    from    which    study  the   making   of   study   models. 

models  are  made. 


using  a  tray  in  the  usual  manner,  and  taking  an  impression  of  each 
arch  separately.  They  can  also  be  made  by  having  the  patient  bite 
into  a  piece  of  soft  modeling  compound,  which  is  shaped  as  shown 
in  Fig.  451.  This  piece  of  soft  modeling  compound  is  placed  in  the 
mouth  in  such  a  position  as  to  include  the  posterior  teeth,  and  the 
patient  is  instructed  to  close  the  mouth.  The  buccal  and  labial  parts 
of  the  modeling  compound  are  worked  around  the  teeth,  up  under  the 
lips,  and  the  patient  is  instructed  to  close  the  lips  Avhile  the  cheeks 
are  manipulated  in  such  a  manner  as  to  work  the  impression  material 
well  toward  the  gingival  border  of  the  teeth.  The  lips  are  held  apart, 
and  the  modeling  compound  is  chilled  by  having  cold  water  sprayed 
on  it  while  the  patient  leans  over  the  cuspidor.  After  the  buccal  and 
labial  parts  have  been  chilled,  the  mouth  is  opened  by  the  pulling  of 
the  lower  teeth  from  the  impression  by  the  patient,  and  while  the  im- 
pression is  still  in  place  on  the  upper  teeth  cold  water  is  sprayed  on 


336  PRACTICAL    ORTHODONTIA 

the  palatal  part  of  the  impression.  By  chilling  the  palatal  part  after 
the  lower  teeth  have  been  removed  from  the  impression,  and  while 
the  upper  teeth  are  in  place,  any  great  amount  of  warpage  is  pre- 
vented and  the  impression  will  be  fairly  accurate,  although  not  so 
accurate  as  a  plaster  impression  would  be.  The  appearance  of  the 
impression  upon  removal  is  shown  in  Fig.  452.  These  study  impres- 
sions can  be  made  in  a  few  minutes  with  the  appliance  in  place,  and 
serve  as  a  valuable  means  of  checking  up  the  treatment  or  retention. 
In  pouring  the  study  impressions,  the  models  should  be  poured  so  that 
there  will  be  an  extension  to  the  distal  of  the  molars  on  the  upper 
and  lower  models  to  act  as  a  guide  in  placing  the  models  in  the  correct 
position.  These  guides  on  the  posterior  parts  of  the  models  are  ex- 
tremely valuable  in  cases  in  which  the  anterior  teeth  are  in  infra- 
occlusion.     The  appearance  of  the  study  model  is  shown  in  Fig.  453. 


Fig.   453. — Study   model   made   from   modeling  compound    impression.      (Lourie.) 

Duplicating  Orthodontia  Models. — Very  often  one  desires  to  make 
a  duplicate  from  the  original  model.  In  order  to  do  this  it  is  neces- 
sary to  use  some  process  that  will  injure  the  original  model  but  little 
and  still  give  a  reproduction  or  duplicate  that  will  be  accurate.  Sev- 
eral processes  have  been  devised,  all  of  which  are  more  or  less  similar. 
The  plan  described  by  Hoggan*  is  as  simple  as  any  and  requires  as 
little  special  equipment  or  material  as  any  process.     It  is  as  follows: 

"Flake  glue  (Fig.  454)  is  prepared  in  thin  chips  about  one-thirty- 
second  inch  in  thickness.  It  is  the  glue  that  is  used  for  duplicating 
plaster  decorations  on  ceilings  and  statuary.  The  ordinary  variety  of 
glue  is  not  suitable  for  this  purpose.    A  tin  dish  about  8  inches  long, 


*Hoggan,  J.  A.  C. :     Duplicating  Orthodontia  Models,  International  Journal  of  Orthodontia, 
July,  1915,  vol.  i,  p.  357. 


IMPRESSIONS    AND    MODELS 


337 


4  inches  wide  and  3  inches  deep  (Fig.  455)  is  the  right  size  to  contain 
two  models  and  sufficient  glue.  An  ordinary  double  boiler,  the  inside 
portion  to  contain  about  two  quarts,  completes  the  necessary  appara- 
tus. The  inside  portion  of  double  boiler  is  filled  with  flake  glue,  and 
sufficient  cold  water  is  then  added  to  cover.  This  is  allowed  to  stand 
until  the  glue  becomes  softened,  usually  about  thirty  minutes.  Half 
of  the  water  is  then  removed  from  the  glue.     Water  is  placed  in  the 


Fig.   454. — Flake  glue.      (Hoggan.) 


outer  boiler,  the  two  parts  of  the  boiler  put  together  and  placed  over 
the  flame.  It  is  allowed  to  heat  until  the  water  in  the  inside  boiler 
rises  to  the  top  of  the  glue.  The  double  boiler  is  then  removed  from 
the  flame  and  the  whole  mass  is  allowed  to  stand  until  liquid,  after 
which  the  inside  boiler  is  lifted  out  of  the  hot  water  in  the  lower  por- 
tion, and  the  glue  allowed  to  stand  until  a  scum  begins  to  form  on  the 
surface,  when  it  is  ready  to  pour.  The  models  to  be  duplicated  are 
first  thinly  coated  with  vaseline  and  placed  in  a  tin  dish  with  teeth 


338 


PRACTICAL   ORTHODONTIA 


presenting  upward  (Fig.  455)  and  the  glue  poured  over  them.  The 
secret  of  the  success  of  this  process  is  to  make  the  mass  of  glue  liquid 
at  the  lowest  possible  temperature,  then  to  pour  it  over  the  models  at 


Fig.   455. — Tin  dish  with   models  placed  in   bottom  ready   to  be  poured  with  glue.      (Hoggan.) 


Fig.   456. — Glue   impression   after  models   have   been   removed.      (Hoggan.) 


the  moment  in  which  it  is  still  liquid,  but  beyond  which  it  would  con- 
geal.   If  models  have  a  tendency  to  rise  in  liquid  glue,  they  may  be 


IMPRESSIONS   AND    MODELS 


339 


Original. 


Fig.   457. 


Duplicate. 


Original. 


Fig.  458. 


Duplicate! 


Original.  Fig.  459.  Duplicate. 

Original  and   duplicate  models.      (Hoggan.) 


340 


PRACTICAL   ORTHODONTIA 


cemented  to  the  bottom  of  the  pan  with  a  little  sticky  wax.  This  is 
allowed  to  stand  in  a  cool  place  for  at  least  twelve  hours,  after  which 
congealed  glue  is  removed  from  the  pan  and  the  models  are  carefully 
lifted  out  by  springing  the  glue  aside.  The  glue  impression  is  now 
ready  to  pour  (Fig.  456)  with  plaster  of  Paris.  These  models  may  be 
removed  from  the  impression  in  ten  minutes  but  are  set  aside  for  an 
hour  to  allow  the  surface  of  the  model  to  set,  it  being  softer  than 
ordinary  models  for  the  depth  of  one-quarter  inch.  Figs.  457  to  461 
show  models   removed   from  the   glue   impression.      The   models   are 


Original.  Fig.   460. 

Original  and   duplicate  models.      (Hoggan.) 


Duplicate. 


Original.  Fig.  461. 

Original  and   duplicate  models.      (Hoggan.) 


Duplicate. 


then  retouched,  and  if  desired  several  sets   can  be  reproduced  from 
the  same  glue  impression." 

Photographs. — A  valuable  adjunct  to  the  records  as  supplied  by 
models  is  the  use  of  photographs  of  the  patient,  and  facial  casts. 
There  are  advantages  in  both  the  photograph  and  the  cast.  In  taking 
photographs  of  patients,  a  side  view  and  a  front  view  should  be  se- 
cured. The  side  view  should  be  a  full  profile,  which  sometimes  is 
rather  difficult  to  get  owing  to  the  fact  that  the  photographers  do  not 


IMPRESSIONS   AND    MODELS 


341 


always  pose  the  patient  so  as  to  give  the  best  results.  Photographs 
which  show  the  proper  poses  are  shown  in  Figs.  462,  463,  464,  and  465. 
With  those  patients  who  are  mouth-breathers  it  is  sometimes  well  to 
take   a  front  view  showing  the  lips  closed  and   one   showing  them 


Fig.     462. — Showing     abnormal     facial     outline     Fig.    463. — Showing   fairly    normal    outline    due 
due  to  mouth-breathing.      (Parsons,)  to   forced   normal   breathing.      (Parsons.) 


Fig.    464. — Showing    fairly    normal    profile    due     Fig.     465. — Showing    abnormal    profile    due    to 
to    forced    normal    breathing.       (Parsons.)  mouth-breathing  and   distoclusion.    (Parsons.) 


342  PRACTICAL   ORTHODONTIA 

pa  lied,  as  shown  in  Figs.  462  and  463.  The  profile  taken  in  the  same 
manner  is  also  shown  in  Figs.  464  and  465.  The  photographs  can  be 
easily  obtained  without  any  discomfort  to  the  patient,  and  for  that 
reason  they  have  been  much  used  during  the  last  few  years.  They  are 
not  so  satisfactory  in  some  other  respects  as  facial  casts. 

Facial  Casts. — Facial  casts  show  the  different  facial  developments 
better  than  does  the  photograph  and  are  especially  desirable  in  those 
patients  who  have  unequal  developments  in  the  two  parts  of  the  face. 
Facial  casts  are  divided  into  the  full  east  and  the  profile ;  we  also  have 
partial  facial  casts  and  the  full  facial  cast  with  the  dental  insert. 

Profile  Cast. — The  technique  of  making  the  profile  cast  will  be  given 
first,  as  it  is  probably  the  more  easily  made.  The  patient  is  placed 
in  a  comfortable  position  in  the  chair,  or  better  still  lies  on  a  table. 
A  piece  of  soft  lead  wire,  or  fuse  wire,  is  made  to  fit  the  facial  profile 
by  starting  with  the  wire  at  the  top  of  the  cranium  and  adapting  it 
to  the  anatomic  curves  along  the  median  line  of  the  face,  along  the 
nose,  upper  lip,  lower  lip,  chin  and  neck,  as  shown  in  Fig.  466.  When 
this  is  done,  the  wire  is  carefully  removed  and  laid  on  a  piece  of  heavy 
cardboard  and  pushed  down  sufficiently  hard  to  make  an  indentation 
in  the  cardboard,  and  the  outline  of  the  wire  is  carefully  marked  on 
the  cardboard  with  a  pencil.  The  cardboard  is  then  cut  out  to  fit  the 
face,  as  shown  in  Fig.  467.  This  cardboard  must  fit  the  facial  profile 
carefully,  for  it  will  serve  as  a  means  of  limiting  the  plaster  to  the 
part  of  the  face  that  is  to  be  included  in  the  facial  cast,  and  will  pre- 
vent annoyance  to  the  patient  from  the  spreading  of  the  plaster  over 
more  of  the  face  than  is  necessary.  The  side  of  the  face  that  is  to  be 
included  in  the  profile  is  then  coated  with  thin  vaseline,  which  has 
been  liquefied  by  placing  the  jar  of  vaseline  in  warm  water.  The 
vaseline  should  not  be  completely  liquid  but  should  possess  enough 
body  so  that  it  may  be  applied  with  the  aid  of  a  shaving  brush.  The 
vaseline  is  placed  over  all  parts  of  the  face  that  are  to  be  included 
in  the  profile  cast,  including  the  hair,  eyebrows,  eyelashes,  the  ear, 
the  nasal  opening,  mouth,  cheeks,  lips  and  neck.  Especial  care  must 
be  taken  to  paint  sufficient  vaseline  on  the  hair  and  eyebrows  so  that 
they  will  not  adhere  to  tin-  cast.  The  eyelashes  must  also  have  enough 
vaseline  on  them  so  that  they  will  pull  free  from  the  facial  impres- 
sion. If  there  is  any  fine  hair  on  the  face  it  must  also  be  care- 
fully painted  down  with  vaseline  to  avoid  the  discomfort  to  the  pa- 
tient that  will  be  experienced  in  the  removal  of  the  cast  should  the 
hair  cling  to  the  cast,  A  piece  of  cotton  containing  vaseline  should 
be  placed  in  the  side  of  the  nose  that  will  be  included  in  the  impres- 


IMPRESSIONS   AND   MODELS 


343 


Fig.   466. — Adjustment  of  fuse  wire  to  center  of  face.      (Oliver.) 


~w% 

1 1    $8 

^^ 

^ 

Fig.   467. — Cardboard   trimmed   to   fit  outline   of  face.      (Oliver.) 


344 


PRACTICAL   ORTHODONTIA 


sion.  A  piece  of  cotton  should  also  be  placed  in  the  opening  of  the 
external  ear,  and  a  piece  of  cotton  saturated  with  vaseline  should  be 
placed  behind  the  ear  to  prevent  the  plaster  from  filling  the  space  be- 
hind the  ear  so  closely  as  to  prevent  the  removal  of  the  cast  from 
the  ear.  After  the  face  and  parts  have  been  thoroughly  covered  with 
vaseline,  the  patient's  head  is  turned  so  that  the  part  of  the  face  to 
be  included  in  the  impression  is  turned  upward,  and  the  piece  of 
cardboard  is  placed  on  the  face  to  prevent  the  plaster  from  spreading 
over  the  face  beyond  the  desired  area.  The  plaster  is  mixed  in  a 
large  mixing-bowl,  one  that  will  hold  at  least  two  quarts  of  the  mixed 


Fig.   468. — Profile   impression   on   face   with    cardboard    removed.      (Oliver.) 


plaster.  The  first  plaster  that  is  placed  on  the  face  should  not  be 
thick  enough  or  stiff  enough  to  displace  the  parts  and  should  be  care- 
fully worked  into  the  fine  lines  and  concavities  of  the  face.  After  this 
first  thin  layer  of  plaster  has  begun  to  set,  more  plaster  can  be  added 
to  give  the  impression  the  desired  thickness.  In  taking  a  facial  pro- 
file cast,  it  is  necessary  to  have  an  assistant  who  holds  the  cardboard 
form  in  place,  and  also  one  who  assists  in  getting  the  plaster  on  the 
face,  as  the  plaster  must  be  laid  on  the  face  very  rapidly  so  that  it 
will  not  set  in  patches,  or  that  part  of  it  will  not  begin  to  set  before 
the  entire  face  is  covered.  It  is  often  necessary  to  make  a  second 
mixture  of  plaster  to  strengthen  the  first  that  has  been  placed  on  the 


IMPRESSIONS   AND    MODELS 


345 


face.  After  the  impression  is  set  the  cardboard  can  be  removed, 
leaving  the  impression  in  place,  as  shown  in  Fig.  468.  After  the  im- 
pression is  thoroughly  hardened,  it  is  carefully  lifted  from  the  face. 
If  sufficient  vaseline  has  been  placed  on  the  hair,  eyebrows,  and  eye- 
lashes, they  will  pull  away  from  the  impression  without  any  discom- 
fort to  the  patient.  Should  the  hair  cling  to  the  impression,  it  can 
be  carefully  worked  loose  by  pushing  the  skin  away  from  the  cast 
with  the  fingers  or  a  spatula.     After  the   impression  is  removed,   it 


Fig.    469. — Facial    impression    grooved    for    separation.       (Oliver.) 


should  be  thoroughly  dried  and  then  given  a  coat  of  shellac  varnish, 
the  same  as  is  used  in  a  plaster  impression  of  the  mouth.  If  there  are 
any  small  air  bubbles  or  other  imperfections,  they  can  then  be  filled 
up  by  the  use  of  a  brush  with  dry  plaster  and  water.  The  coating  of 
shellac  will  furnish  a  line  of  demarkation  so  that  the  plaster  can  be 
added  only  where  it  is  desired.     A  second  coating  of  shellac  is  then 


346 


PRACTICAL    ORTHODONTIA 


IMPRESSIONS   AND    MODELS 


347 


placed  on  the  impression,  and  after  it  is  dry  a  coating  of  sandarac 
varnish  is  applied.  After  the  sandarac  varnish  is  dry,  the  impression 
is  ready  to  pour,  which  is  done  by  mixing  enough  plaster  to  entirely 
fill  the  impression  to  about  the  thickness  of  half  an  inch.  This  mix- 
ture of  plaster  is  poured  in  the  impression  and  the  impression  turned 
from  side  to  side  to  get  the  plaster  into  all  of  the  fine  lines  and  to 
distribute  it  equally  inside  the  impression.  Immediately,  a  second 
mixture  is  placed  in  the  impression  for  the  purpose  of  increasing  the 
thickness  and  of  giving  it  more  strength.  After  the  cast  has  become 
hard,   the   impression   can   be   removed   in   the    same   manner    that   a 


Fig.    4~2. — Fuse   wire   used   to   get  outline   of  face   for   partial   facial   cast.      (Oliver.) 


plaster  impression  is  removed  from  the  teeth.  Deep  grooves  are  cut 
in  the  impression,  as  shown  in  Fig.  469,  until  the  discoloration  of  the 
shellac  is  seen.  Care  must  be  observed  in  removing  the  ear,  lips, 
nose  and  eyebrows.  After  the  impression  has  been  removed,  the  cast 
can  be  trimmed  to  bring  out  the  profile,  and  the  imperfections  can  be 
remedied  with  the  use  of  plaster  and  a  brush.  Fig.  470  shows  the 
finished  profile  cast,  front  view.  The  back  of  the  profile  cast  is  com- 
pleted by  cutting  holes  in  the  plaster,  into  which  two  corks  are  in- 
serted and  pasted  by  placing  some  soft  plaster  around  them.  Screw- 
eyes  can  then  be  placed  in  the  corks,  and  the  cast  hung  up,  if  so  de- 
sired (Fig.  471). 


348 


PRACTICAL    ORTHODONTIA 


Partial  Facial  Cast. — A  partial  facial  cast  includes  only  a  part  of 
the  face  and  does  not  include  the  ears,  or  one  ear,  as  does  the  profile 
cast.  They  are  much  easier  to  make  as  they  are  easy  to  remove  and 
may  not  include  the  hair  or  eyes.  They  are  made  by  taking  a  piece  of 
cardboard  and  by  cutting  a  hole  in  it  large  enough  to  include  the 
chin,  mouth,  part  of  the  cheeks,  and  the  nose.  Provision  has  to  be 
made  for  the  patient  to  breathe  through  the  nose,  and  rubber  tubes 
are  placed  in  the  nares  through  which  the  patient  breathes.  These 
tubes  should  not  be  so  large  as  to  distort  the  nose,  yet  they  must  be 
large  enough  so  that  the  patient  can  breathe  through  them  with  com- 
fort.   The  partial  facial  cast  can  also  be  extended  so  as  to  include  the 


Fig.   473. — Cardboard  in  place  for  the  partial  facial  cast  showing  rubber  tubes  in  nose.      (Oliver.) 


eyes,  in  which  case  the  technique  consists  in  taking  a  piece  of  fuse 
wire  and  in  making  an  oval  to  include  the  parts  of  the  face  that  are 
to  be  included  in  the  cast.  The  fuse  wire  is  shaped  as  shown  in  Fig. 
472.  This  piece  of  wire  is  then  laid  over  the  piece  of  cardboard  and 
serves  as  a  pattern  for  cutting  the  cardboard  that  fits  over  the  face, 
as  shown  in  Fig.  473.  The  position  of  the  rubber  tubes  is  also  shown. 
In  order  that  the  end  of  the  tube  can  be  held  away  from  the  lip,  a 
piece  of  string  is  fastened  to  it.  The  assistant  can  hold  the  rubber 
tube  out  of  the  way  while  the  plaster  is  being  placed  around  the  tube. 
Care  must  be  observed  not  to  displace  the  rubber  tube  or  the  breath- 


IMPRESSIONS   AND    MODELS 


349 


Fig.   474. — Impression   for   partial    facial   cast   showing  position   of  tubes  and  cardboard.      (Oliver.) 


Fig.  475. — Partial  facial  cast.      (Oliver.) 


350  PRACTICAL   ORTHODONTIA 

ing  of  the  patient  will  be  interfered  with  and  the  impression  will  be 
spoiled.  The  face  is,  of  course,  coated  with  vaseline  in  the  same  way 
as  it  was  in  the  profile  casts,  and  the  plaster  is  applied  to  the  face  in 


Fig.  476. — Fartial  facial  casts.      (Parsons.) 


Fig.  477. — Partial  facial  casts.      (Parsons.) 


the  same  manner.  The  appearance  of  the  face  covered  with  plaster, 
and  the  position  of  the  rubber  tubes  and  the  cardboard,  are  shown 
in  Fig.  474.    The  impression  is  varnished  in  the  same  way  as  was  the 


Impressions  and  models 


351 


impression  of  the  facial  profile,  and  poured  and  separated  in  the  same 
manner.  Fig.  475  shows  the  facial  cast,  front  view,  which  does  not 
include  the  ears.  Fig.  476  shows  the  side  view  of  a  partial  facial  cast, 
and  Fig.  477  the  front  views. 

Full  Facial  Cast. — In  making  a  full  facial  cast  the  fuse  wire  is  ad- 
justed to  the  face  and  cranium  so  as  to  include  the  ears  and  chin 
and  as  much  of  the  cranium  as  is  desired.  It  is  generally  necessary  to 
include  only  that  part  of  the  cranium  as  far  back  as  the  ears.    A  piece 


Fig.  478. — Full  facial  cast  with  dental  insert.      (Oliver.) 


of  cardboard  is  then  cut  to  fit  the  face  and  the  face  is  covered  with 
vaseline  as  in  the  other  impressions.  After  the  face  has  been  covered 
with  vaseline,  the  plaster  is  applied  to  the  face  in  the  same  manner 
as  in  the  profile,  and  when  the  first  coat  or  layer  of  plaster  has  been 
reenforced,  the  facial  impression  is  removed.  In  some  instances  the 
full  facial  impression  can  be  removed  in  one  piece,  and  in  other  cases 
it  will  be  necessary  to  break  it  in  order  to  free  it  from  the  posterior 
part  of  the  mandible.  The  impression  is  varnished  and  poured  and 
separated  in  the  usual  manner. 


352 


PRACTICAL    ORTHODONTIA 


Full  Facial  Cast  With  Dental  Insert. — The  full  facial  cast  is  also 
made  with  an  insert  of  the  teeth,  an  example  of  which  is  shown  in 
Fig.  478.  It  will  be  observed  that  the  teeth  are  shown  in  the  full  cast, 
and  that  they  occupy  the  same  relation  in  the  cast  that  they  occupy 
in  the  face.  This  makes  possible  the  study  of  the  teeth  in  relation  to 
the  face  in  a  manner  that  has  never  before  been  possible  without  the 
insert  cast.  In  making  the  dental  insert,  the  face  is  coated  with 
vaseline,  and  the  rubber  tubes  are  placed  in  the  nose,  as  is  shown 


Fig.   479. — Impression    of   teeth   and   face   for   the    dental   insert.      (Oliver.) 


in  Fig.  473.  It  is  not  necessary  to  use  a  cardboard  to  control  the 
plaster  in  making  the  dental  insert.  The  patient  holds  the  teeth  to- 
gether, the  lips  are  separated,  and  soft  plaster  is  worked  between  the 
teeth  and  the  cheeks  as  far  distally  as  the  last  tooth.  A  good  amount 
of  plaster  is  placed  in  the  oral  vestibule  so  as  to  include  all  of  the 
alveolar  process  on  the  buccal  sides  and  on  the  labial  side  of  the 
teeth,  and  thus  give  the  necessary  strength.  After  the  oral  vestibule 
is  full  of  plaster,  it  is  continued  over  the  face,  covering  the  chin,  nose, 
and  median  part  of  the  forehead.  It  is  necessary  to  have  the  facial 
part  of  the  dental  insert  impression  cover  the  points  mentioned  on  the 


IMPRESSIONS    AND    MODELS 


353 


face  in  order  to  have  three  points  that  are  fixed  for  the  placement 
of  the  insert  in  the  facial  impression.  The  appearance  of  the  dental 
insert  impression  after  the  plaster  has  been  placed  over  the  chin,  nose, 
and  forehead  is  shown  in  Fig.  479.  The  impression  is  then  varnished 
in  the  same  manner  as  are  the  other  facial  impressions,  and  is  shown  in 
Fig.  480.  The  impression  is  poured,  and  after  the  removal  of  the 
dental  insert  cast,  the  facial  parts  are  trimmed  away,  leaving  only 
three  points  nntrimmed,  which  are  the  tip  of  the  nose,  the  center  of 


Fig.    480. — Facial    an  J    dental    insert    impression    varnished.      (Oliver.) 


the  forehead,  and  the  tip  of  the  chin  (Fig.  481).  This  trimming  is 
done  to  allow-  the  plaster  that  is  poured  in  the  full  facial  impression 
to  flow  around  the  dental  insert  at  all  points,  except  the  three  points 
mentioned  and  the  part  that  is  protected  with  wax,  as  is  shown  in 
Fig.  482.  The  part  of  wax  that  is  shown  in  Fig.  482  is  to  prevent  the 
plaster  from  flowing  over  the  entire  dental  insert  when  it  is  placed  in 
the  facial  impression  and  wdien  the  facial  impression  is  poured.  The 
wax  protection  is  made  by  taking  a  piece  of  soft  wax,  molding  it  over 
the  side  of  the  dental  insert,  and  then  trimming  it  approximally.  The 
wax  can  then  be  warmed,  and  the  dental  insert  with  the  wax  in  position 


354 


PRACTICAL    ORTHODONTIA 


Fig.  481. — Dental  insert  cast  ready  to  be  placed   in  facial  impression.      (Oliver.) 


Fig.    482. — Wax    protection   of   side   of   dental    insert   to   prevent   plaster   from   flowing   over   teeth 

(Oliver.) 


IMPRESSIONS   AND    MODELS 


355 


Fig.   483. — Clamp   for   holding   dental  insert   in  facial   impression.      (Oliver.) 


Fig.  484.— Dental  insert  in  facial  impression.      (Oliver.) 


356 


PRACTICAL   ORTHODONTIA 


is  placed  in  1  lie  facial  impression  with  the  point  of  the  nose,  forehead, 
and  chin  in  the  proper  relations,  and  the  wax  forced  into  the  proper 
form  and  shape.  The  dental  insert  can  then  be  removed  and  the  wax 
added  to  or  trimmed  as  desired.  After  the  wax  has  been  properly- 
shaped,  the  next  step  is  to  hold  the  dental  insert  in  the  facial  impres- 
sion in  the  proper  place  while  the  facial  impression  is  poured.  The 
dental  insert  is  held  in  place  by  a  clamp,  shown  in  Fig.  483,  which 


Fig.   485. — Facial  cast  with  iron  or  wood  in  position  for  holding  it.      (Oliver.) 


consists  of  a  steel  bow  that  is  threaded,  large  enough  to  encircle  the 
outside  of  the  facial  impression.  A  steel  cross-bar  is  used,  which  car- 
ries a  central  screw,  with  a  slot  in  each  end  to  receive  the  steel  bow, 
and  which  is  wide  enough  to  accommodate  the  posterior  width  of  the 
facial  impression.  The  dental  insert  is  placed  in  the  facial  impression 
and  held  in  position  by  the  clamp,  as  shown  in  Fig.  484.  In  order 
that  the  central  set-screw  may  have  a  firm  grip  on  the  dental  insert, 


IMPRESSIONS    AND    MODELS 


357 


it  is  well  to  make  a  hole  in  the  hack  side  of  the  dental  insert  into  which 
a  cork  can  be  fitted.  This  cork  gives  a  more  secure  hold  for  the 
set-screw  than  the  plaster  does,  which  might  crumble  under  pressure 
and  thereby  allow  the  dental  insert  to  become  displaced.  After  the 
dental  insert  has  been  secured  in  place,  the  facial  impression  is  filled 
with  soft  plaster,  care  being  taken  to  work  it  around  the  dental  in- 
sert in  such  a  manner  as  to  fill  all  of  the  space  between  the  dental 
insert  and  the  walls  of  the  facial  impression.     After  the  first  layer 


Fig.   486. — Facial   cast  with  wax  insert  in  position.      (Oliver.) 


of  plaster  is  placed  in  the  facial  impression,  a  second  layer  is  added 
to  give  the  facial  cast  the  proper  thickness  and  strength.  In  order  to 
provide  some  means  to  hold  the  facial  cast,  a  piece  of  iron  or  strong 
wood  is  imbedded  in  the  cast  at  the  time  the  second  layer  of  plaster 
is  placed  in  the  impression,  as  shown  in  Fig.  485.  The  facial  impres- 
sion is  removed  from  the  east  in  the  same  manner  as  has  been  de- 
scribed in  the  other  casts.  The  facial  cast  with  the  wax  insert  in 
position  is  shown  in  Fig.  486.  Figs.  478  and  487  show  a  view  of  the 
facial  cast  with  the  dental  insert  in  position.    The  value  of  the  facial 


358 


PRACTICAL    ORTHODONTIA 


cast  with  the  dental  insert  is  that  it  gives  the  relation  of  the  teeth  to 
the  face,  and  the  different  tooth  movements  can  be  observed  with  re- 
gard to  the  fixed  positions  of  the  face. 

Some  men  have  objected  to  the  facial  cast  because  of  the  trouble 


Fig.  487. — Front  view  of  facial  cast  with  dental  insert  in  position.     (Oliver.) 

necessary  to  make  it.  This  objection  is  not  well  founded,  for  the  facial 
impression  can  be  made  in  a  few  minutes  and  is  not  a  great  annoyance 
to  the  patient.  The  facial  cast  with  the  dental  insert  has  so  many 
points  of  superiority  over  everything  else  as  a  matter  of  record  that 
it  is  well  worth  anyone's  time  to  master  the  necessary  technique. 


CHAPTER  X 

USE  OF  THE  X-RAY  IN  ORTHODONTIA 

By  James  David  McCoy,  D.D.S. 

It  is  no  longer  necessary  to  present  an  argument  in  favor  of  the  use 
of  the  x-ray  in  any  of  the  various  branches  of  dentistry,  as  its  merits 
and  possibilities  are  now  recognized  by  all  open-minded  and  progressive 
members  of  the  dental  profession. 

Orthodontists  were  among  the  first  in  the  profession  to  recognize  the 
valuable  aid  to  be  gained  through  the  adoption  of  this  agent  as  a  regular 
part  of  office  routine,  and  as  a  result,  many  of  the  uncertainties  and  per- 
plexing situations  incident  to  orthodontic  practice  have  been  clarified. 

That  the  orthodontist  should  maintain  his  own  x-ray  laboratory  is 
no  longer  a  debatable  point.  With  it  he  is  able  to  utilize  the  x-ray 
whenever  the  necessity  for  its  use  arises,  without  subjecting  patients 
or  himself  to  the  inconvenience  or  added  expense  incident  to  referring 
them  to  a  roentgenologist ;  and  what  is  even  more  important,  with  it 
conveniently  at  hand,  he  will  use  it  whenever  indicated,  instead  of  limit- 
ing its  use  to  cases  of  dire  necessity. 

It  is  only  logical,  therefore,  to  assume  that  an  essential  part  of  thei 
preparation  of  the  student  or  practitioner,  who  is  to  undertake  ortho- 
dontic procedures,  will  include  the  basic  principles  of  radiography, 
which  entails  a  knowledge  of  the  nature  of  the  x-ray,  the  electrophys- 
ics  of  its  production,  the  intelligent  handling  of  x-ray  apparatus,  the 
technique  of  radiography,  the  development  of  plates  and  films,  the  inter- 
pretation of  radiograms,  as  well  as  a  knowledge  of  the  dangers  arising 
through  the  misuse  of  the  x-ray. 

Taking  it  for  granted  that  the  reader  is  thus  prepared,  it  will  there- 
fore be  unnecessary  to  discuss  here  any  phases  of  the  above  enu- 
merated principles,  other  than  touching  upon  a  few  practical  suggestions 
in  technique  of  special  significance  to  the  orthodontist. 

Owing  to  the  fact  that  patients  undergoing  orthodontic  treatment  are 
usually  children  whose  ages  necessitate  their  being  handled  with  tact 
and  gentleness  if  confidence  is  maintained,  precaution  should  be  taken  to 
rid  every  operation  of  fear  or  discomfort.  Especially  is  this  essential  in 
making  radiograms,  for  any  considerable  degree  of  movement  on  the 

359 


360  PRACTICAL    ORTHODONTIA 

part  of  a  patient  will  either  curtail  the  value  of  the  finished  radiogram, 
or  perhaps  render  it  useless. 

The  Question  of  Technique 

To  obtain  a  radiogram  of  any  portion  of  the  body,  it  is  necessary  to 
have  a  photographic  or  x-ray  plate  or  film  (properly  prepared  so  as  to 
exclude  all  light  and  moisture)  placed  in  such  a  position  that  the  x-rays 
may  pass  through  the  desired  structures  and  register  their  shadows  with 
the  least  amount  of  distortion  possible  upon  the  plate  or  film. 

In  securing  radiograms  of  the  dental  and  oral  structures,  two  gen- 
eral methods  of  procedure  are  open  to  us,  each  of  which  has  its  value 
and  special  indications.  These  are  known  as  the  "  infra-oral' '  and  "ex- 
tra-oral ' '  methods. 

With  the  first  named,  small  films  are  used,  which  are  placed  within 
the  mouth  opposite  the  area  to  be  radiographed,  and  held  in  position 
either  by  means  of  a  film  holder,  or  by  the  assistant,  or  better  still,  by 
the  patient  exerting  slight  pressure  with  the  finger.  This  method  is  in- 
dicated when  radiograms  of  small  areas  only  are  desired;  as,  for  in- 
stance, two  or  three  teeth,  with  the  adjacent  alveolar  process. 

With  the  other  method  of  procedure  mentioned,  namely,  the  extra- 
oral  method,  large  plates  or  films  arc  used,  and  the  areas  desired  are 
brought  in  as  close  contact  as  possible  with  the  plate,  by  pressing  or 
resting  the  side  or  portion  of  the  face  in  which  the  structures  are  lo- 
cated against  it.  The  rays  are  then  passed  through  the  structures  from 
the  other  side  of  the  skull,  in  such  a  manner  as  to  cause  the  shadows  of 
the  desired  structures  to  be  imposed  upon  the  plate.  By  using  this 
method,  large  areas  may  be  radiographed,  which  in  some  instances,  will 
embrace  the  lateral  half  of  both  the  upper  and  lower  jaws  from  the 
region  of  the  lateral  incisors  anteriorly  to  the  angle  of  the  jaws  pos- 
teriorly, and  from  the  floor  of  the  orbit  above  to  the  inferior  margin  of 
the  mandible  below.  In  fact,  it  is  possible,  by  making  several  exposures, 
to  obtain  in  detail  a  radiographic  representation  of  the  dental  apparatus 
in  toto,  as  well  as  its  associated  organs  and  structures,  the  nasal  cavity, 
pneumatic  sinuses,  the  maxilla,  and  mandible. 

In  selecting  a  method  of  procedure  for  making  radiograms  of  chil- 
dren, the  child's  comfort  must  be  taken  into  consideration,  and  with 
this  idea  in  mind,  the  author  has  found  it  an  advantage  to  use  the  ex- 
tra-oral method  quite  universally.  In  fact,  he  has  used  it  in  nearly 
all  cases  except  where  the  region  embracing  the  upper  anterior  teeth 
is  under  scrutiny.    The  wisdom  of  this  course  will  be  apparent  to  any- 


USE    OF    X-RAY    IN    ORTHODONTIA 


361 


one  who  has  experienced  the  discomfort  of  having  intra-oral  films  placed 
lingually  to  the  mandibular  teeth,  where  the  tissues  are  very  sensitive, 
or  has  had  them  placed  back  in  the  molar  region,  against  the  palate, 
where  they  so  frequently  induce  gagging.  These  unpleasant  features 
are  all  eliminated  by  using  the  extra-oral  method,  and  good  radiograms 
of  the  structures  desired  can  be  secured  on  the  larger  plates.  This  state- 
ment should  not  be  construed  as  a  protest  against  the  use  of  intra-oral 
lilms  in  dental  radiography,  for  it  is  very  often  necessary  to  use  such 
films  with  adult  patients  where  a  high  degree  of  detail  is  essential  in 


Fig.    488. — The    arrangement    of    tin-    apparatus    preparatory    to    seating    the    patient.       (  McCoy.) 


determining  the  condition  about  non-vital  teeth,  root  canal  fillings,  etc. 
In  orthodontic  practice,  however,  where  we  are  dealing  with  young  sub- 
jects entirely,  a  sufficient  degree  of  detail  can  be  obtained  in  the  major- 
ity of  instances,  using  the  extra-oral  method  to  satisfy  the  needs  of 
the  operator. 

Seating  the  Patient 

In  preparing  the  patient  to  be  radiographed,  it  is  important  that  a 
suitable  chair  be  provided,  which  will  afford  ample  support,  not  only  for 
the  head,  but  will  make  it  possible  for  the  patient  to  be  sufficiently 


362 


PRACTICAL    ORTHODONTIA 


Fig.    489. — Position   of   patient's   head   for   extra-oral    exposure.      (McCoy.) 


Fig.  490. — Radiogram  obtained  from  position  shown  in  Fig.  489.     (McCoy.) 


USE    OP    THE    X-RAY    IN    ORTHODONTIA 


363 


Fig.    491. — Position    of   patient's    head    for    extra-oral    exposure.      (McCoy.) 


Fig.    492. — Radiogram    obtained    from    extra-oral    exposure    to    determine    presence    of    permanent 

teeth.      (McCoy.) 


364 


PRACTICAL   ORTHODONTIA 


comfortable  to  remain  quiet,  without  difficulty.  For  this  purpose,  the 
dental  chair  may  be  used,  or  if  this  is  not  convenient  to  the  x-ray  appa- 
ratus, the  ordinary  armchair  with  a  headrest  may  be  utilized.  The 
author  has  found  it  an  advantage  to  use  the  ordinary  chair  with  a 
straight  back  and  small  arms,  placed  against  the  back  of  the  dental  chair 
(Fig.  488) .  The  headrest  of  the  dental  chair  is  turned  over  and  adjusted 
to  the  proper  height,  position  and  angle  to  support  the  patient's  head. 
If  the  extra-oral  method  is  being  utilized,  the  headrest  wings  are  flat- 
tened out  to  make  a  resting  place  for  the  plate.  In  this  way,  the  pa- 
tient's head  is  afforded  the  firm  support  of  the  heavy  dental  chair,  and 


Fig.    493. — Position   of   patient's   head   for   intra-oral   exposure   of   incisors.      (McCoy.) 


the  plate  is  held  in  an  immobile  state  without  difficulty  and  the  operator 
can,  by  making  a  few  changes  in  the  position  of  the  small  chair,  and  by 
moving  and  readjusting  the  headrest,  have  radiographic  access  to  any 
part  of  the  dental  structures  (Figs.  489  to  493).  The  fact  that  this  re- 
quires but  a  few  moments,  does  not  disarrange  the  office,  or  put  the  pa- 
tient to  discomfort,  justifies  the  author  in  feeling  that  it  is  an  excellent 
method  for  use  in  the  dental  office.  Of  course,  it  is  necessary  where  this 
method  is  followed,  to  have  the  x-ray  machine  and  accessory  apparatus 
in  the  same  room  with  the  dental  chair.  Where  this  is  not  possible,  it  is 
an  easy  matter  to  attach  an  adjustable  headrest  to  the  ordinary  straight- 
back  chair,  and  by  having  the  patient  change  positions  in  the  chair,  ac- 
complish the  same  result. 


USE   OF    THE   X-RAY   IN    ORTHODONTIA 


365 


Fig.    494. — Radiogram    to    show    space    necessary    for   impacted    premolar.      (McCoy.) 


Fig.  495. — Radiogram  to  show  space  necessary  for  impacted  canine.      (McCoy.) 


3G6 


PRACTICAL    ORTHODONTIA 


Indications  for  the  Use  of  the  X-ray  by  the  Orthodontist 

The  necessity  for  using  the  x-ray  in  orthodontic  practice,  varies  with 
different  patients,  but  generally  speaking,  may  be  summarized  under  ten 
different  headings  as  follows : 

1.  As  a  means  of  determining  the  presence  or  absence  of  unerupted 
permanent  teeth  before  treatment  is  started. 


Fig.    496. — Radiogram   to   show   space   necessary   for   impacted   tooth.      (McCoy.) 


The  majority  of  patients  requiring  orthodontic  treatment  usually  have 
a  mixed  dentition;  that  is,  they  usually  have  present  in  the  mouth,  the 
deciduous  molars  and  cuspids.  It  is  essential,  therefore,  to  determine 
whether  or  not  these  deciduous  teeth  all  have  permanent  successors.  If 
the  upper  and  lower  incisors  have  erupted,  information  concerning  the 
other  permanent  teeth  is  easily  obtained,  by  making  a  radiogram  of  each 
side  by  the  extra-oral  method.  Such  radiograms  are  shown  in  Figs.  490 
and  492. 

Such  radiograms  give  the  operator  a  very  adequate  survey  of  these 
unerupted  teeth,  and  leave  no  doubt  as  to  their  presence  or  absence. 


USE    OF    THE    X-RAY    IN    ORTHODONTIA 


367 


2.  As  a  means  of  determining  the  approximate  size  of  unerupted 
teeth,  for  which  spurt  mast  be  made  in  the  arches. 

Where  the  deciduous  molars  or  cuspids  have  been  lost  prematurely, 
with  the  usual  resultant  loss  of  space  in  the  arch  involved,  the  radio- 
gram can  be  made  to  show  quite  accurately  the  amount  of  space  which 
it  will  be  necessary  to  establish,  if  adequate  space  is  to  be  prepared  for 
the  unerupted  teeth  (Figs.  4!>4.  495,  and  496). 


Fig.   497. — Radiogram  showing  condition  of  unerupted   second   molar.      (McCoy.) 


3.  To  determine  the  state  of  development  of  unerupted  teeth  which 
are  tardy  in  their  eruption. 

Not  infrequently  permanent  teeth  fail  to  come  through  when  expected. 
By  utilizing  the  radiogram  their  degree  of  development  is  easily  deter- 
mined, and  often  the  cause  for  their  noneruption  is  determined.  Steps 
can  then  be  taken  to  open  up  spaces,  and  hold  them  until  such  a 
time  as  the  teeth  involved  progress  in  their  development  to  the  point  of 
eruption  (Fig.  497). 


368 


PRACTICAL    ORTHODONTIA 


4.  To  determine  the  approximate  direction  in  which  teeth  are  erupting, 
and  the  relationship  which  they  will  hare  to  the  line  of  occlusion  when 
<  rupted. 

Where  the  deciduous  teeth  have  been  retained  in  the  mouth  longer  than 
their  normal  period,  and  where  the  roots  of  these  teeth  have  not  been  en- 
tirely absorbed,  the  erupting  permanent  teeth  will  sometimes  be  deflected 


Fig.     498. — Radiogram     to     show     direction     of 
erupting  teeth.     (McCoy.) 


Fig.  499. — Radiogram  to  show  location  of 
canine  to  aid  in  making  attachment.  (Mc- 
Coy.) 


Fig.     500. — Radiogram    to    show    location     of 
lateral  incisors  and  anomalous  teeth.   (McCoy.) 


Fig.    501. — Same    as    Fig.    500    with   attachment 
on    lateral    incisor.       (McCoy.) 


out  of  their  normal  course.  It  is  an  advantage  to  know  the  direction  in 
which  they  are  deflected,  so  that  if  retaining  appliances  are  to  be  placed, 
they  may  be  arranged  in  such  a  way,  and  in  such  a  relationship  to  the 
erupting  teeth  that  they  will  not  interfere  with  them.  In  fact,  it  is  some- 
times possible  to  construct  the  retainer  in  such  a  way  that  the  tooth  which 
is  deflected  out  of  its  course  may  be  guided  towards  its  normal  position, 


USE   OF    THE    X-RAY   IN    ORTHODONTIA 


369 


Fig.   502. — Radiogram  to  show  conditions  in  tardy  loss   of  deciduous  tooth.      (McCoy.) 


Fig.    503. — Unerupted    upper   second    bicuspid    retarded    in    its    eruption    by    the    presence    of    the 
deciduous   second   molar.      (McCoy.) 


370  PRACTICAL    ORTHODONTIA 

or  moved  there  before  the  inclined  planes  of  the  opposing  teeth  become 
a  factor  in  establishing  it  entirely  out  of  its  normal  position  (Fig.  498). 

5.  As  a  guide  where  it  is  necessary  to  make  attachments  to  unerupted 
teeth,  to  aid  in  their  eruption. 

While  it  is  not  often  necessary  to  secure  attachments  to  teeth  lying  be- 
neath the  gingival  tissues,  the  occasion  for  this  sometimes  arises,  as  shown 


Fig.    504. — Radiogram  .showing    relation  .of  .  in-         Fig..  505.— Radiogram    showing    relation    of    ca- 
cisor    roots  '  to    canine.  '    (McCoy.)  nines   to   centrals.      (McCoy.) 


Fig.   506. — Radiogram  showing  relation  of  per-        Fig.   507. — Radiogram  showing  position  of  ca- 
manent  canine.     (McCoy.)  nine   root.      (McCoy.) 


in  Figs.  499,  500,  and  501.  In  such  cases,  radiograms  should  be  made 
as  a  guide  in  securing  the  attachment.  After  the  attachment  is  secured, 
others  should  be  made  to  determine  the  direction  in  which  force  should 
be  applied  to  accomplish  the  desired  tooth  movement. 


USE   OF    THE   X-RAY   IN   ORTHODONTIA 


371 


6.  To  determine  the  most  opportune  time  for  the  extraction  of  the  de- 
ciduous teeth. 

Where  the  deciduous  tooth  persists  in  the  mouth,  and  shows  no  sign  of 
being  shed,  it  is  an  advantage  to  determine  the  extent  of  absorption  of 
the  roots,  as  well  as  the  development  of  its  successor,  so  that  if  extraction 
is  resorted  to,  it  can  be  done  with  the  knowledge  that  the  developing 
tooth  will  not  be  disturbed  or  injured,  and  that  the  successor  has  reached 
a  degree  of  development  which  will  insure  its  eruption  within  a  reason- 
able time  (Figs.  502  and  503). 


Fig.    508. — Radiogram    showing   location    of    erupting    lower    third    molars.       (McCoy.) 


7.  To  observe  the  movement  of  the  roots  of  teeth  and  their  relation- 
ship to  other  roots  and  structures. 

In  the  bodily  movement  of  teeth,  and  particularly  of  the  incisors,  it  is 
important  in  young  subjects  that  these  roots  do  not  encroach  upon  each 
other  or  upon  other  teeth ;  for  instance,  an  unerupted  cuspid.  It  is, 
therefore,  advisable,  where  any  doubt  exists,  to  determine  the  exact 
status  of  this  relationship  (Figs.  504  to  512). 


372 


PRACTICAL    ORTHODONTIA 


8.  To  determine  the  relationship  of  developing  third  molars  to  cer- 
tain recurrent  malocclusions,  and  also  as  a  precaution  so  that  steps  may 
be  taken  to  prevent  these  teeth  from  becoming  a  cause  of  malocclusion 
during  their  eruption. 

The  pressure  exerted  by  developing  lower  third  molars  is  often  suffi- 
ciently great  to  cause  a  crowding  of  the  lower  incisors  and  cuspids  (Figs. 
508  and  509).  This  can  be  true,  even  though  malocclusion  has  not  ex- 
isted in  this  region  previous  to  the  development  of  the  third  molars.    By 


Fig.    509. — Radiogram  showing  position   of  lower  third   molars.      (McCoy.) 


making  radiograms  from  time  to  time,  of  those  patients  who  are  of  an 
age  for  development  and  erupting  these  teeth,  the  status  of  the  develop- 
ing teeth  can  be  determined  and  the  necessary  precautions  taken  to  pre- 
vent the  crowding  of  the  incisors  and  cuspids. 

9.  To  observe  non-vital  teeth  prior  to  tooth  movement,  to  determine 
their  fitness  for  movement  or  anchorage,  and  their  state  of  health  during 
the  process  of  orthodontic  treatment. 


USE   OF    THE   X-RAY    IN    ORTHODONTIA  373 

Where  it  is  necessary  to  either  move  non-vital  teeth,  or  utilize  them 
as  anchorage,  it  is  essential  to  the  patient's  welfare  and  comfort  to  know 
that  such  teeth  and  their  investing  tissues  are  in  a  healthy  condition.  By 
determining  this  prior  to  instituting  orthodontic  treatment,  much  trou- 
ble both  to  the  patient  and  operator  can  often  be  avoided  (Fig.  510). 

10.  In  rusts  where  anomalous  teeth  are  present,  to  differentiate  be- 
tween  anomalous  and  normal  teeth. 


Fig.    510. — Radiogram    to    show    condition    of        Fig.  511. — Radiogram  showing  anomalous  tooth, 
mandibular  molar  which  is  used  for  anchorage.  i  McCoy.) 

(McCoy.) 


Fig.    512. — Radiogram   showing   absence   of   mandibular   centrals.      (McCoy.) 

Iii  a  majority  of  instances,  this  can  be  clone  without  the  aid  of  the 
radiogram,  unless  the  teeth  in  question  have  failed  to  erupt.  Under  such 
conditions,  by  utilizing  accuracy  in  the  technique  of  making  the  radio- 
grams, little  difficulty  is  encountered  in  determining  the  difference  be- 
tween normal  and  anomalous  teeth.  (Examples  are  shown  in  Figs.  500, 
511  and  512.) 


CHAPTER  XI 

TREATMENT  OF  CASES 
Neutroclusion,  or  Class  1 

Cases  of  neutroclusion,  or  Class  I,  present  many  different  features. 
They  resemble  each  other  in  that  they  have  a  normal  mesio-distal  re- 
lation of  the  arches.  In  other  respects  they  may  differ  a  great  deal, 
as  shown  by  the  different  types  that  were  described  under  classifica- 
tion. 

Taking  up  the  treatment  of  the  simpler  malocclusions  of  this  class 
first,  we  shall  consider  the  treatment  of  such  cases  as  are  shown  in  Fig. 


Fig.  513. — Neutroclusion,  or  Class  I,  case.     Lingual  occlusion  of  maxillary  incisors  to  mandibular. 

513.  In  this  case,  the  arches  are  in  normal  mesio-distal  relation.  The 
upper  incisors  are  in  lingual  relation  to  the  lower.  In  fact,  the  upper 
teeth  are  lingual  to  their  proper  position  and  the  lower  incisors  are 
labial.  The  patient  is  five  and  one-half  years  old.  If  the  malocclusion 
is  not  corrected,  it  is  certain  that  the  permanent  teeth  will  take  the 
same  position  as  shown  by  the  deciduous  teeth.  The  demand  for  treat- 
ment at  this  age  is  obvious.  If  this  condition  was  allowed  to  exist 
until  the  eruption  of  the  permanent  teeth,  the  malocclusion  would 
probably  develop  into  a  mesioclusion,  or  Class  III,  case. 

374 


.'.  ^ftSA^IKs'l;    C5F  '  CASES  : 


3?5 


The  appliance  lis'edi  in  .'.the  treatment  of  the.  ease  shown  in  Fig.  513 
could  not  be-: improved  upon'  so. far 'as  efficiency  was  concerned,  the 
only  ob jection.. being,  that  .of. CQUspicuousness  of  the  appliance  on  the 
maxillary  teeth.  In  order  to  have  an  appliance  that  would  be  incon- 
spicuous on  the  maxillary  teeth,  it  would  be  possible  to  use  a  lingual 
wire  soldered  to  bands  on  the  second  deciduous  molars.     The  incisors 


Fig.    514. — Appliance    for    moving    maxillary    incisors    labially    and    mandibular    incisors    lingually. 


Fig.   515. — Completed  case  of   Fig.   514. 

would  be  carried  forward  by  pinching  the  lingual  wire  in  the  premolar 
region  as  illustrated  by  Fig.  257.  This  gives  an  appliance  on  the  upper 
teeth  that  cannot  be  seen  at  all. 

Plain  bands,  made  as  described  in  Chapter  V,  were  placed  on  the 
upper  and  lower  canines.  On  the  upper  bands,  a  wire  was  soldered  on 
the  labial  side,  far  enough  labially  to  permit  the  incisors  to  be  brought 


376 


PRACTICAL    ORTHODONTIA 


Initially  to  their  proper  position.  On  the  lingual  side  of  the  lower  ca- 
nines a  wire  was  soldered,  far  enough  lingually  to  permit  the  lower 
teeth  to  be  moved  lingually.     The  appliances  are  shown  in  Fig.  514. 


Fig.    516. 


Fig.   517. 
Figs.    516   and    517. — Si'lc    and    front    views    of   neutroclusion,    or    Class    I,    case. 

The  upper  and  lower  teeth  were  tied  to  the  respective  appliances  by 
silk  ligatures  that  exerted  force  on  the  teeth.  In  a  few  weeks  the  teeth 
were  in  the  position  shown  in  Fig.  515  and  were  retained  for  a  short 


TREATMENT   OP    CASES 


377 


time  by  fastening  them  to  the  appliance  by  means  of  wire  ligatures, 
which  exerted  a  passive  force. 

Figs.  516,  517,  and  518  show  a  case  of  neutroclusion,  or  Class  I,  the 
upper  central  incisors  and  right  lateral  incisor  b.eing  in  linguover- 
sion.  The  left  lateral  incisor  is  in  torsiversion.  The  lower  incisors 
are  slightly  in  labioversion.  A  space  exists  between  the  lower  left 
lateral  and  canine,  which  shows  the  distance  the  lower  anterior  teeth 
are  mesial.  After  studying  the  case  carefully,  the  author  came  to  the 
conclusion  that  the  position  of  the  mandibular  teeth  was  the  result  of 
the  malocclusion  with  the  upper,  and  if  the  maxillary  incisors  were 
moved  labial   to   the   mandibular,    the   force   of  the   maxillary   teeth 


Fig.    518. — Black    line    indicates   position    expansion    arch    should    occupy    to    the    upper    teeth    and 

gingival  margin. 

against   the   mandibular   teeth   would   force   the    mandibular   incisors 
lingually  to  their  proper  position. 

The  maxillary  teeth  were  treated  by  placing  clamp  bands  on  the  first 
molars.  The  screw  was  so  placed  that  it  occupied  the  position  shown  in 
Fig.  520,  which  also  shows  the  position  of  the  tube  on  the  molar  band. 
The  arch  Avas  bent  and  adjusted  so  as  to  stand  away  from  the  anterior 
teeth,  as  they  are  the  only  ones  that  have  to  be  moved.  On  the  maxil- 
lary left  lateral  incisor,  a  plain  band  was  placed  with  a  spur  soldered 
near  the  disto-gingivo-lingual  angle.  The  position  of  the  arch  is  shown 
in  Figs.  519  and  520.  Wire  ligatures  were  then  placed  on  the  upper 
anterior  teeth  and  twisted  tightly.  At  first,  the  greatest  force  was 
placed  on  the  central  incisors  so  as  to  avoid  too  much  pressure  on  the 


378 


PRACTICAL   ORTHODONTIA 


molars.  After  the;  central  .incisors'  started  to  move,  force  was  placed 
on  the  lateral  incisors.  After  the  teeth  .had  started  to  move,  the  three 
incisors,  which  are  not  rotated,  were  carried  labially  by  tightening 


Fig.    519. — Side   view    showing    position    of    arch    in    premolar    region.      Band    on    left    canine    to 

rotate  same. 


Fig.   520. — Occlusal  view  of  arch.     Band  was  used  on  left  lateral,  but  is  not  shown. 

the  nuts  on  the  expansion  arch :  that  is,  by  screwing  the  nuts  distally. 
The  wire  ligature  on  the  left  lateral  incisor  was  tightened  at  each 
visit  so  as  to  correct  the  torsiversion  of  the  lateral,  on  which  was 


-  TREATMENT   OF    CASES 


379 


placed  a  plain  band  -with- a  spuiv  After,  the  maxillary:  teeth  were 
moved  into  the  position  shown  in  Fig.  521,  the  teeth  were  retained  by 
passive  retention,  as 'shown  in  Fig. "522.  ':  The  retaining  appliance  was 


Fig. 


Fig.    522. — Showing   retention    of    Fig.    518. 

worn  until  the  maxillary  canine  erupted,  for  it  was  necessary  to  re- 
tain the  space  for  the  permanent  canine  as  the  deciduous  canine  was 
soon  lost.  The  occlusion  of  the  upper  incisors  with  the  lower  teeth 
carried  the  lowers  distally  and  closed  the  space  between  the  lateral 


380  PRACTICAL    ORTHODONTIA 

and  canine,  as  shown  in  Fig1.  523.    This  ease  was  one  belonging  to  the 
third  type  of  Class  I. 

Fig.  524  shows  a  ease  of  neutroclusion  with  linguoversion  of  the 
left  maxillary  incisor  and  an  underdeveloped  condition  of  the  max- 
illary and  mandibular  teeth.  Plain  bands  were  placed  on  the  first 
molar  of  both  arches.  Lingual  wires  were  soldered  to  the  lingual 
surfaces  of  the  molar  bands  made  for  19-gauge  iridio-platinum.  By 
pinching  the  lingual  wires  with  the  wire-stretching  pliers,  expan- 
sion was  produced  in  both  arches.  The  labial  movement  of  the  left 
maxillary  incisor  was  produced  by  a  finger  spring  soldered  to  the 
lingual   wire    as    shown    in   Fig.    525.     By    springing   the    maxillary 


Fig.   523. — Completed    case    of    Fig.    518.      Note    how    occlusion    has    driven    lower    anterior    teeth 
distally   and    closed   space   between   canine   and    premolar. 

lingual  wire  occlusally  it  was  possible  to  so  adjust  the  finger  spring 
as  to  make  the  left  maxillary  incisor  assume  a  position  shown  in  Fig. 
526. 

Fig.  527  shows  the  position  of  the  molars  at  the  beginning  of  treat- 
ment. Owing  to  the  loss  of  the  maxillary  deciduous  molars,  the  per- 
manent molar  assumed  the  normal  position  in  the  maxillary  arch. 
The  mandibular  deciduous  molars  were  retained,  which  held  the  first 
permanent  molar  distally.  In  the  beginning  of  the  treatment  the 
right  mandibular  molar  was  used  as  an  anchor  tooth  carrying  the 
lingual  wire  which  prevented  the  right  permanent  molar  from  moving 
forward.     As  soon  as  the  incisal  and  canine  portion  of  the  mandib- 


TREATMENT    OF    CASKS 


381 


tilar  arch  was  corrected  the  lingual  appliance  was  changed  by  remov- 
ing the  band  from  the  right  mandibular  molar,  and  using  a  lingual 
wire  extending  from  the  left  molar  to  the  right  second  incisor  as  a 
retaining  appliance.  This  appliance  left  the  right  molar  free  to 
move  forward  as  can  be  seen  in  Fig.  528.  In  using  a  form  of  ap- 
pliance care  should  be  exercised  to  select  such  teeth  as  anchorage, 


Fig.   524. 


Fig.   525.' 


Fig. 


Fig.    527. 


as  can  be  used  without  interfering  with  the  natural  development  of 
the  arches. 

Fig.  529  shows  another  case  of  neutroclusion,  or  Class  I,  that  is 
typical  of  a  great  many  cases  belonging  to  this  class  and  is  one  of  the 
first  type.  In  order  to  treat  this  case,  it  will  be  necessary  to  expand 
both  the  upper  and  the  lower  arch.    The  upper  arch  is  underdeveloped 


382 


PRACTICAL   ORTHODONTIA 


about  equally  on  both  sides,  and  therefore  the  teeth  will  all  have  to 
be  moved  equally  with  the  exception  of  the  upper  canines,  which  will 
have  to  be  depressed  slightly.  The  front  view  (Fig.  529)  shows  that 
the  median  line  of  the  upper  and  lower  incisors  is  not  a  straight  line. 


Fig.   528. 


Fig.    529. — Neutroclusion,    or    Class    I,    case.      Normal    mesio-distal    relation    of   arches. 

This  is  caused  by  the  fact  that  the  lower  incisors  have  drifted  to  the 
right.  The  right  lateral  is  distal  to  the  canines  and  all  of  the  lower 
incisors  will  have  to  be  moved  to  the  left. 


TREATMENT   OF    CASES 


383 


Ligature  wires  are  twisted  between  the  teeth,  as  described  in  Chap- 
ter V,  so  as  to  produce  enough  separation  to  permit  putting  on  the 
molar  bands.  Clamp  bands  are  placed  on  the  upper  and  lower  first 
molars,  as  shown  in  Figs.  530  and  531.     Plain  bands  could  have  been 


Fig.   530. 


Fig.   531. 

Figs.   530   and   531. — Occlusal   view   of   appliances.      Spurs    on    lower   arch    to   move    teeth 

toward   left   side. 


used  on  this  case  as  satisfactorily  as  clamp  bands.  The  upper  arch  is 
adjusted  in  such  a  manner  that  it  stands  away  from  the  second  pre- 
molars slightly  and  a  little  farther  away  from  the  first  premolars. 


384  PRACTICAL    ORTHODONTIA 

A  bend  is  made  in  the  canine  region  so  that  the  arch  lies  below  the 
tip  of  the  canine.  No  effort  is  made  to  place  the  arch  labially  to  the 
maxillary  canines,  for  it  would  be  too  prominent  and  hold  the  lip 
out  too  far.  The  arch  stands  labially  to  the  incisors,  as  shown  in 
Fig.  530.  In  order  to  exert  force  on  the  upper  canines  to  depress 
them,  tube-spurs  are  soldered  to  the  arch,  as  shown  in  Fig.  532.  These 
spurs  are  bent  to  fit  the  labial  convexity  of  the  canine  and  by  bend- 
ing the  spur  with  a  pair  of  pliers,  force  is  exerted  on  the  canines  to 
depress  them.  This  pressure  can  be  increased  by  putting  a  rubber  wedge 
between  the  canine  and  wire  spur.  The  molar  bands  are  placed  on  the 
mandibular  first  molars  and  the  arches  adjusted,  as  shown  in  Fig.  530. 
Fig.  531  shows  the  shape  of  the  lower  alignment  wire.  The  lower 
alignment  wire  is  bent  so  as  to  assume  a  position  labially  to  the  lower 


Fig.   532. — Front  view,  showing  spurs  to  depress  canines. 

right  canine  and  bent  with  rather  a  sharp  angle  in  the  canine  region. 
Owing  to  the  fact  that  the  mandibular  incisor  must  be  shifted  to  the 
left,  soft  solder  wire  spurs  are  placed  on  the  arch  at  points  shown  in 
Fig.  532  and  the  ligatures  placed  so  as  to  pull  the  teeth  to  the  left.  In 
order  to  increase  the  pull  of  the  teeth  toward  the  left  side,  the  ex- 
pansion arch,  or  alignment  wire,  is  so  adjusted  that  it  stands  away 
from  the  left  canine  region  farther  on  the  left  side  than  it  does  on  the 
right. 

The  maxillary  teeth  Avere  retained  by  placing  bands  on  the  maxillary 
lateral  incisors  and  the  first  molars.     The  first  molar  bands  are  plain 


TREATMENT    OF    CASES 


385 


bands.  A  lingual  wire  was  placed  on  the  lingual  side  of  the  teeth 
to  retain  the  expansion  of  the  arch.  A  spur  was  soldered  on  the  labial 
side  of  the  lateral  incisor  to  make  a  downward  pressure  on  the  canine. 


Fig.   533. 


Fig.   534. 
Figs.    533    and   534. — Occlusal   view   of   retainers.      Compound   reciprocal    intermaxillary    retention. 

The  occlusal  view  of  the  retainer  is  shown  in  Figs.  533  and  534.  The 
lower  arch  was  retained  by  plain  bands  on  the  molars,  left  canine  and 
right  lateral.    A  lingual  wire  was  used  to  retain  the  expansion  of  the 


386  PRACTICAL    ORTHODONTIA 

teeth.  A  spur  was  soldered  on  the  labial  surface  of  the  right  lower 
lateral  band  to  retain  the  canine.  No  band  was  placed  on  the  lower 
right  canine,  for  it  was  in  infra-occlusion,  and  a  band  would  have 
prevented  it  from  elongating  as  it  should.  The  front  view  of  the 
retainer,  which  is  a  compound  reciprocal  retainer,  is  shown  in  Fig. 
535. 

Figs.  536  and  537  show  a  case  of  neutroclusion,  or  Class  I,  in  which 
there  is  bunching  of  the  maxillary  and  mandibular  teeth.  The  front  view 
of  the  case  shows  that  the  median  line  of  the  maxillary  and  mandib- 
ular teeth  is  not  in  balance.  The  maxillary  teeth  have  drifted  to 
the  right  and  the  mandibular  teeth  to  the  left.  The  occlusal  view 
(Figs.  538,  539  afld  540)  shows  the  reason  for  the  shifting  of  the  me- 


Fig.  535. — Front  view  of  retaining  appliance.     Spurs  to  hold  and  move  maxillary  canines 

occlusally. 

dian  line.  The  position  of  the  maxillary  and  mandibular  canines 
is  due  to  the  early  loss  of  the  deciduous  canines,  which  permitted  the 
maxillary  anterior  teeth  to  drift  to  the  right  and  the  mandibular  an- 
terior teeth  to  the  left.  When  the  mandibular  left  canine  erupted,  it 
forced  the  lateral  incisor  lingually  and  took  a  labial  position.  After  sep- 
arating the  molar  teeth,  clamp  bands  were  placed  on  both  the  maxillary 
and  the  mandibular  first  molars.  The  arches  were  bent  in  the  canine 
region  to  give  the  relations  shown  in  Figs.  538,  539  and  540.  Owing 
to  the  infraversion  of  the  right  maxillary  canine,  it  was  necessary  to 
place  a  tube  spur  on  the  arch,  as  shown  in  Fig.  541.  It  will  be  no- 
ticed that  the  spur  is  double,  one  part  of  which  projects  gingivally 
and  distally  and  rests  on  the  labial  surface  of  the   canine  and  the 


TREATMENT   OF    CASES 


387 


other  part  projects  occlusally  and  distally  and  is  used  for  intermax- 
illary anchorage.  In  adjusting  the  upper  arch  it  is  made  to  stand  aAvay 
from  the  canine  and  lateral  on  the  right  side,  and  spurs  are  soldered 


Fig.    536. 


Fig.   537. 
Figs.  536  and  537. — Neutroclusion,  or  Class  I,  case.    Largely  due  to  early  loss  of  deciduous  teeth. 


388 


PRACTICAL   ORTHODONTIA 


Fig.   538. — Occlusal  view,  showing  spurs  on  arch  and  bend  in  arch   on  right  side  to  move  median 
line   to  the  right.     Dotted   line  shows  position   of  arch   before  being  placed   in   tube. 


Fig.    533. — Shows    how    ligatures    spring   arch    toward    teeth.      Dotted    line    represents    position    ol 
arch    before    ligatures    were    placed    on    teeth. 


TREATMENT    OF    CASES 


389 


on  the  expansion  arch  in  the  position  shown  in  Fig.  542.  When  the  lig- 
atures are  placed  on  the  anterior  teeth,  the  arch  will  be  sprung  as  shown 
by  the  dotted  lines.  It  will  now  be  seen  that  the  placing  of  the  wire 
ligatures,  as  shown  by  the  lines,  has  pulled  the  upper  arch  to  the  right 
side.  No  ligature  should  be  placed  on  the  left  lateral  incisor  until 
the  other  three  incisors  have  been  moved  to  the  right  far  enough  to 
give  room  to  bring  it  through.  In  applying  the  wire  ligatures  on  the 
incisors,  the  right  lateral  should  be  ligated  first  as  it  is  the  one  that 
receives  the  greatest  stress;  if  the  centrals  were  ligated  first  and  the 
lateral  last,  it  would  be  found  that  the  ligatures  on  the  centrals  were 


Fig.    540. 


-Shows   relation   of  lower   arch   to   teeth.      Ligatures  and   spurs   on   lower   arch    to   move 
teeth  to  left. 


loose  after  the  lateral  was  ligated.  After  the  three  incisors  have 
begun  to  move,  a  wire  can  be  placed  on  the  left  lateral  and  the  gingival 
part  of  the  tube-spur  bent  down  on  the  canine. 

The  lower  expansion  arch  is  applied  the  same  as  the  upper  arch  ex- 
cept that  the  spring  is  reversed ;  that  is,  the  left  side  of  the  arch  takes 
its  position  away  from  the  canine  region  and  the  spurs  are  soldered  to 
the  arch  at  the  left  side  of  the  teeth  that  are  to  be  moved.  The  position 
of  the  spurs  can  be  seen  by  noting  Figs.  540  and  541.  On  the  right  side 
of  the  lower  arch  is  soldered  a  sheath-hook  for  the  use  of  intermaxil- 
lary anchorage.  The  left  canine,  left  lateral  incisor  and  the  centrals 
are  ligated  to  the  arch,  which  causes  the  arch  to  assume  the  position 
shown  by  the  dotted  lines.     From  the  sheath-hook  on  the  lower  arch 


390 


PRACTICAL    ORTHODONTIA 


Fig.   541. — Double    spur    on    upper    arch.       Gingival    spur    to    depress    canine.       Occlusal    spur    to 
engage   intermaxillary   rubber,    as    shown    in    Fig.    542. 


Fig.   542. — Intermaxillary   rubber   to  assist   in   shifting   median   line   of   upper  and   lower  arch. 


TREATMENT    OF    CASES  391 

to  the  sheath-hook  on  the  upper  arch,  an  intermaxillary  rubber  is 
stretched  and  worn  at  night,  which  assists  in  shifting  the  median  line. 
This  use  of  the  intermaxillary  anchorage  was  first  described  to  the 
author  by  Angle. 

As  a  result  of  the  treatment,  the  teeth  were  brought  to  their  proper 
position  and  the  median  line  of  the  upper  and  lower  arches  corrected, 
as  shown  in  Fig.  543.  The  retention  of  the  upper  arch  consisted  of  a 
plain  band,  which  was  placed  on  the  left  lateral  with  a  spur  on  the 
lingual  side  that  engaged  the  lingual  side  of  the  left  central,  and  a 
spur  on  the  mesial  side  of  the  lateral  band  bearing  against  the  labial 


Fig.    543. — Completed  case. 


surface  of  the  canine,  gingivally  to  the  greatest  convexity;  so  by  bend- 
ing the  spur  downward,  pressure  would  be  brought  to  bear  on  the 
canine  that  would  cause  it  to  assume  the  proper  position  in  the  arch, 
as  it  is  in  infra-occlusion.  Owing  to  the  length  of  the  cusps,  it  was 
impossible  for  the  upper  arch  to  change  unless  the  left  canine  and 
lateral  slipped  out  of  the  line  and  the  mandibular  teeth  changed.  There- 
fore, it  was  important  that  the  lower  arch  be  retained  in  order  to  make 
the  upper  stay.  Bands  were  placed  on  the  lower  canine  and  the  right 
lateral   incisor.     A  wire  was   soldered   to   the   lingual   surfaces   con- 


392 


PRACTICAL    ORTHODONTIA 


necting  the  two  bands.  On  the  labial  side  of  the  lateral  band  was 
soldered  a  spur,  which  engaged  the  labial  surface  of  the  right  canine 
that  had  been  moved  from  labioversion  and  was  still  in  infra  version. 
A  band  intended  for  use  in  compound  retention  should  never  be  placed 


Fig.   544. 


Fig.  545. 

Figs.   544   and   545. — Neutroclusion,   or   Class   I,   case.      Notice  extreme   linguoversion   of   maxillary 

lateral    incisors. 


TREATMENT    OP    CASES 


393 


on  a  tooth  that  is  in  infraversion,  for  it  prevents  the  tooth  from  taking 
its  proper  position  in  the  arch. 

In  removing  the  retaining  appliances  from  a  case  of  this  kind,  the 


Fig.    546. — Upper  appliance  ligated  to   teeth. 


Fig.    547. — Dotted   line   on   lower  shows   relation   of   heels   of  arch   to   tubes   before  arch   is   placed 

in   molar  bands. 


upper  should  be  removed  first  and  the  lower  left  a  month  or  more 
longer.  In  any  case,  all  of  the  retaining  appliances  should  not  be  re- 
moved until  all  of  the  forces  of  occlusion  have  been  established. 


394  PRACTICAL    ORTHODONTIA 

The  right  and  front  view  of  the  case  illustrated  in  Figs.  544  and  545 
shows  it  to  be  one  of  neutroclusion,  or  Class  I,  as  the  arches  are  in 
normal  mesio-distal  relation.  By  looking  at  the  right  side  and  the 
front  view  it  will  be  seen  that  the  right  lateral  and  central  are  in 
lingual  occlusion.  The  occlusal  view  shows  the  right  lateral  in  con- 
tact with  the  premolar.  The  entire  upper  arch  needs  to  be  expanded. 
Ligature  wires  were  placed  on  the  mesial  and  distal  sides  of  the  first 
molars  and  twisted  to  separate  the  teeth  slightly  so  as  to  permit  the 
placing  of  the  molar  bands.  The  molar  bands  were  so  placed  that 
the  tube  lined  buccally  to  the  canine.  While  the  canines  are  promi- 
nent, as  the  teeth  now  stand  there  is  not  sufficient  room  between  them 
to  accommodate  the  incisors.  One  side  of  the  arch  was  placed  in  the 
tube  on  the  molar  band  so  as  to  obtain  the  proper  length  and  alignment. 


Fig.    548. — Showing  method   of   adjusting  arch   by   beginning   at   one   side    and   carefully  adjusting 
same   until   molar   on    opposite  side   is   reached. 

The  arch  is  allowed  to  stand  away  from  the  premolars  and  canine. 
In  the  region  of  the  canine,  the  arch  is  bent  at  an  angle,  as  shown  in 
Fig.  548.  This  bend  is  made  in  one  side  only,  and  the  arch  is  in  one 
tube  only  at  this  time.  The  position  of  the  anterior  part  of  the  arch 
to  the  anterior  teeth  is  now  noted,  and  the  arch  bent  again  in  the 
region  of  the  canine  on  the  opposite  side.  The  buccal  part  of  the  arch 
is  now  aligned  with  the  tube.  Up  to  this  time,  the  arch  has  been 
placed  in  the  tube  on  one  side  only.  With  the  side  of  the  arch  in 
the  tube  that  was  first  adjusted,  the  position  of  the  other  side  is  care- 
fully noted.  It  should  be  observed  how  the  angle  of  the  arch  com- 
pares with  the  angle  of  the  tube  before  being  placed  in  the  tube. 
The  arch  should  also  stand  buccally  to  the  tube,  for  the  molars  re- 
quire expanding  and  a  slight  amount  of  expansive  force  should  now 


TREATMENT    OF    CASES 


395 


buccally  to  the  tube  the  width  of  a  16-gauge  wire  and  will  not  exert 
enough  expansive  force  to  cause  any  pain.  In  adjusting  the  wire 
so  as  to  produce  expansion,  the  spring  that  produces  the  expansion 
be  given  the  arch.     The  arch  or  alignment  wire  can  be  made  to  stand 


wm  Wr^>  ^ 

33  '^Px         j*^t 
g  By 

^^H 

Hf 

n 

Sr  W£'         ^W 

\LJw9 

Ik                 ilBiini 

J 

Pig.  549.  —  Plain  bands  with  spurs  were  placed  on  the  laterals,  but  are  not  shown  on  this 
model.  Upper  arch  does  not  touch  canines  as  those  teeth  must  be  expanded.  Spur  opposite 
right   lateral   is   for   bodily   movement   of   same. 


Fig.    550. — Front    view    of    appliances.      Right    maxillary    lateral    incisor    is    ligated    to    arch    after 
sufficient    room   has   been   made   to   allow   it   to   move. 


396  PRACTICAL   ORTHODONTIA 

must  be  derived  from  the  anterior  segment  of  the  wire,  and  never 
from  the  heels  or  the  distal  corners,  or  the  molars  will  rotate  buccally. 
The  position  of  the  adjusted  arch  to  the  teeth  is  shown  in  Figs.  549  and 
550.  The  positions  of  the  ends  of  the  arch  to  the  tubes  before  they  are 
placed  in  the  tubes  are  shown  by  the  dotted  lines.  Bands  are  placed  on 
the  laterals  with  spurs  so  that  they  can  be  rotated  and  also  to  prevent 
the  ligatures  from  slipping  off.  A  spur  is  soldered  on  the  arch  at  a 
point  directly  labially  to  the  mesial  surface  of  the  right  lateral,  as  the 
tooth  must  be  moved  directly  labially  in  order  to  get  past  the  canine. 
After  the  premolars  have  been  expanded  slightly  and  the  incisors 
moved  labially,  it  will  be  necessary  to  place  a  tube-spur  on  the  upper 
arch  so  as  to  move  the  apex  of  the  right  lateral  forward.    This  spur  rests 


Fig.  551. — Cross  section   of  arch  and  spur  for  bodilv   movement  of  teeth  shown  in   Figs.   549    and 

550.  ' 


against  the  incisal  edge  of  the  tooth,  which  prevents  that  part  from 
moving,  and  by  tightening  the  ligature  the  apex  is  brought  forward. 
The  position  of  the  spur  is  shown  in  Figs.  549,  550,  and  551. 

There  is  nothing  unusual  or  new  in  the  adjusting  of  the  lower  arch 
as  the  teeth  need  expanding  slightly.  The  left  lower  canine  must  be 
banded  so  as  to  permit  its  rotation. 

The  teeth  of  the  upper  and  lower  arch,  having  been  expanded,  are 
retained  by  compound  reciprocal  retention,  so  as  to  permit  them  to  re- 
spond to  the  forces  of  occlusion.  Bands  are  placed  on  the  upper  lateral 
incisors.  A  spur,  long  enough  to  engage  the  lingual  surface  of  the  cen- 
tral incisor,  is  soldered  on  the  lingual  side  of  each  band.  A  long  spur, 
extending  back  to  the  mesial  portion  of  the  upper  first  molar,  is  sol- 
dered on  the  labial  surface  of  the  lateral  band.     This  long  spur  rests 


TREATMENT    OF    CASES 


397 


against  the  upper  canine  on  the  labial  surface.  Ligature  wires,  which 
have  had  a  piece  soldered  to  them  as  shown  in  Fig.  552,  to  prevent  their 
slipping  under  the  gum,  are  placed  on  the  first  and  second  premolars. 


Fig.   552. 


Fig.   553. 
Figs.    552   and    553.  —Impressions   made   after   retaining   appliances    were   placed   on   teeth. 

This  plan  of  soldering  a  wire  on  the  ligature  wire  to  prevent  it  from 
slipping  under  the  gum  was  suggested  to  the  author  by  Lourie.  Af- 
ter the  premolars  have  been  ligated  to  the  labial  spur  we  have  the 


398 


PRACTICAL    ORTHODONTIA 


retaining  appliance,  as  shown  in  Pig.  554.  The  advantage  of  this  form 
of  retainer  is  that  none  of  the  teeth  are  held  rigid,  and  by  bending 
the  spurs  different  amounts  of  force  can  be  brought  to  bear  on  dif- 
ferent teeth.  The  greatest  tendency  for  the  teeth  to  return  to  their 
former  position  is  in  the  region  of  the  tirst  premolar,  canine  and 
lateral.  This  tendency  is  prevented  by  the  use  of  the  retaining  ap- 
pliance, which  has  been  so  constructed  as  to  make  possible  the  highest 
degree  of  compound  active  reciprocal  retention.  The  lower  teeth  were 
retained  by  the  device  shown  in  Fig.  553. 


Fig.   554. — Front  view,   showing  long  labial   spur  over  canine. 


Fig.  555  shows  the  occlusal  view  of  a  model  before  and  after  treat- 
ment, in  which  it  was  necessary  to  expand  the  upper  arch  as  well  as  the 
lower  arch,  but  the  particularly  interesting  thing  in  the  treatment  of 
this  case  was  the  manner  in  which  the  maxillary  lateral  incisors  were 
moved  bodily.  The  appliance  used  in  this  case  consisted  of  a  high 
labial  arch  the  position  of  which  can  be  seen  in  Figs.  556  and  557. 
This  appliance  as  used  by  Lourie  on  this  case,  consisted  of  plain 
bands  upon  the  molars,  the  buccal  tubes  to  receive  a  17-gauge  gold 
and  platinum  straight  alignment  wire.  This  alignment  wire  mesial 
to  the  buccal  tubes  on  the  nut  on  the  alignment  wire  is  bent  gingivally 
so  as  to  make  the  anterior  portion  of  alignment  wire  occupy  position 
above  the  gingival  line  of  the  tooth.  The  object  of  this  is  to  make  the 
appliance  less  conspicuous  as  well  as  to  make  possible  the  use  of  a 
long  finger   spring  with   a   recurved    extension,   as   can   be   seen   by 


TREATMENT    OF    CASES  399 

studying  Figs.  556  and  557.  This  recurved  spring  extension  is  made 
of  24-gauge  gold  and  platinum  spring  wire  or  of  22-gauge  gold  spring 
wire  which  is  tapered  down  at  a  point  occlusal  to  the  solder  attach- 
ment to  the  heavy  alignment  wire  until  it  is  the  size  of  the  24-gauge 
wire,  the  short  end  of  which  goes  into  a  24-gauge  tube.  It  has  been 
found  by  practice  and  experience  that  the  elasticity  in  a  24-gauge 
wire  is  sufficiently  strong  to  produce  an  apical  movement  of  the  tooth 
and  not  sufficiently  strong  to  produce  any  amount  of  pain  or  soreness 
in  the  tooth  as  it  is  being  corrected.  The  advantage  of  the  high  labial 
wire  is  first,  inconspicuousness,  and  second  from  a  mechanical  stand- 
point, it  has  the  advantage  of  the  use  of  a  long  spring  which  gives 
a  greater  amount  of  elasticity  than  is  found  in  any  other  method  for 
bodily  or  apical  tooth  movement.  On  the  left  central  incisor  it  will 
be  observed  that  there  is  a  finger  spring  resting  against  the  labial 
surface,  which  was  for  the  purpose  of  depressing  that  tooth.  The  ap- 
pliance was  first  adjusted  so  that  it  could  act  directly  upon  the  lateral 
incisor,  which  has  bands  carrying  a  perpendicular  tube  for  the  pur- 
pose of  receiving  a  short  end  of  the  J  wire.  By  having  this  finger 
extension  on  the  lateral  incisor  made  in  the  form  of  a  J,  it  is  possible 
to  control  any  torsiversion  which  is  present  in  the  teeth,  as  can  be 
observed  by  studying  Fig.  560.  After  the  maxillary  teeth  had  been 
expanded  and  moved  to  the  proper  position,  the  canines  then  erupted, 
and  it  was  found  necessary  to  place  bands  on  the  canine  carrying  a 
short  spur  or  lug  which  received  a  long  spring  extension  soldered  to 
the  labial  alignment  wire,  and  which  can  be  observed  by  studying 
Figs.  556  and  557.  This  spring  extension  resting  upon  the  canine  lug 
would  assist  in  its  eruption  and  correct  the  torsiversion  which  is  shown 
in  the  illustration.  In  Fig.  561  it  will  be  noticed  that  the  end  of  the 
spring  extension  which  rests  over  the  lug  on  the  canine  band  is  bent 
in  the  form  of  a  curve  and  that  the  curve  portion  of  the  spring  ex- 
tension rests  upon  the  lug  on  the  canine.  As  this  spring  extension 
exerts  considerable  pressure  on  the  lug  on  the  canine  band  the  curved 
end  of  the  spring  extension  also  exerts  a  distal  action  which  is  suffi- 
cient to  carry  the  canine  distally  to  its  proper  position.  The  use  of 
the  high  labial  arch  with  the  recurve  spring  extension  as  shown  in 
Figs.  555,  556,  and  557  makes  one  of  the  most  efficient  methods  for 
apical  tooth  movement  and  also  for  the  correction  of  torsiversion  that 
the  author  has  ever  used. 

The  case  illustrated  by  Fig.  558  has  a  normal  mesio-distal  relation 
of  the  arches  on  both  sides.  The  maxillary  teeth  on  the  right  side, 
from  the  central  to  second  molars,  are  in  lingual  occlusion,  except 


400 


PRACTICAL    ORTHODONTIA 


Fig.   555.      (After   Lourie.) 


Fig.    556.      (After   Lourie.) 


Fig.    557.      (After   Lourie.) 


TREATMENT   OF    CASES  401 

the  canine.  This  makes  it  necessary  to  expand  or  move  the  maxillary 
teeth  on  the  right  side  farther  than  we  shall  move  the  same  teeth  on 
the  left  side.  It  will  therefore  be  impossible  to  use  reciprocal  an- 
chorage, which  has  to  a  certain  extent  been  employed  in  the  former 
cases.  In  order  to  move  the  teeth  that  are  in  lingual  occlusion  to  their 
proper  position,  we  have  the  choice  of  several  methods  and  an- 
chorages. We  can  use  reenforeed  simple  anchorage,  stationary  anchor- 
age, or  intermaxillary  anchorage. 

In  using  reenforeed  simple  anchorage,  the  molar  bands  are  adjusted 
to  the  first  molars  in  the  usual  manner.    The  arch  is  placed  in  the  tubes 


Fig.    SS8. — Neutroclusion,    or   Class    I,    case.      Maxillary    molars    and    premolars    on    right    side    in 

linguoversion    to    mandibular. 

on  the  molar  bands  with  expansion  in  the  molar  regions.  If  nothing 
else  was  now  done,  there  would  be  an  equal  amount  of  force  exerted 
on  the  molars  of  both  sides,  which  is  not  desired.  However,  in  order 
that  the  molar  on  the  left  side  may  have  the  advantage  over  the  one 
on  the  right  side,  the  screw  on  the  left  molar  band  is  bent  against  the 
premolar,  as  in  Figs.  559  and  560,  and  away  from  the  premolar  on  the 
right  side.  This  enlists  two  teeth  on  the  left  side  against  one  on  the  right 
side.  To  further  increase  the  anchorage  on  the  left  side,  the  first 
premolar  and  canine  are  ligated  to  the  arch.  This  now  makes  re- 
enforced  simple  anchorage,  as  a  number  of  teeth  on  the  left  side  are 
pitted  against  the  tooth  on  the  right  side.     Owing  to  the  attachment 


402 


PRACTICAL    ORTHODONTIA 


of  the  peridental  membrane  and  the  alveolar  process,  it  will  be  im- 
possible to  move  the  right  first  molar  without  exerting  some  force  on 
the  second  molar  and  second  premolar.     In  fact,  when  expanding  the 


Fig.    559. — Showing  arch   before   it   is  placed  in   tube. 


Fig.  560. — Showing  arch  after  having  been  placed  in  tubes. 

first  molar  in  cases  of  this  kind,  it  is  seldom  necessary  to  attach  to 
the  second  molar.  In  order  to  increase  the  buccal  movement  of  the 
right  molar,  intermaxillary  anchorage  can  be  used  by  placing  a  rub- 


TREATMENT   OF    CASES 


403 


Fig.   561. — Front  view  of  arches  in  position. 


Fig.   563. 

Fig.   562. — Rubber  ligature   from   screw  on  lingual  side   of  right  maxillary  molar  band  to   tube 
on  right  mandibular  molar  band. 

Fig.   563. — Showing  oval  and   square  tubes   for  stationary   anchorage   of   molars. 


404 


PRACTICAL   ORTHODONTIA 


ber  ligature  from  the  screw  on  the  lingual  side  of  the  right  upper 
molar  band  to  the  tube  on  the  right  lower  molar  band.  This  will 
make  the  rubber  occupy  the  relation  as  shown  in  Fig.  562.  If  rubber 
ligatures  of  good  quality  are  used,  they  will  resist  the  stress  of  mas- 
tication remarkably  well. 


Fig.    564. 


Fig.   565. 
Figs.    564   and    565 — Front   and    occlusal    view    of    Fig.    558,    showing    retention. 


It  has  been  stated  that  the  molars  and  premolars  on  the  right  side 
could  be  moved  by  stationary  anchorage.  Stationary  anchorage  can  be 
produced  in  several  ways.  One  way  is  to  use  an  oval  tube ;  the  arch 
is  also  oval,  which  prevents  the  arch  from  turning  in  the  tube  (Fig. 
563).  This  oval  tube  is  used  on  the  left  side  or  the  side  that  is  to  be 
made  stationary.     A  square  tube  serving  the  same  purpose  has  been 


TREATMENT    OF    CASES 


405 


devised  by  Kemple.  If  the  oval  or  square  tube  cannot  be  obtained, 
stationary  anchorage  can  be  produced  by  the  use  of  the  ordinary 
round  tube  and  expansion  arch  in  the  following  manner.  The  arch 
is  adjusted  to  the  teeth  and  bent  to  align  with  the  tube  as  it  should. 
On  the  left  side  the  tube  is  pinched  to  the  arch  by  means  of  heavy 
pliers  or  a  Avire  cutter.  Then  the  nut  on  the  band  is  loosened  and  the 
band  removed  with  the  arch  in  the  tube.  The  tube  is  then  soldered 
to  the  arch  by  means  of  soft  solder.  Soldering  the  arch  in  the  tube 
makes  the  tipping  of  the  left  molar  impossible  unless  the  arch  bends. 
The  bending  of  the  arch  must  be  taken  into  consideration  in  any  of 
the  forms  of  anchorage  that  we  have  mentioned.  Care  must  be  ex- 
ercised so  as  not  to  strain  the  anchor  tooth. 

Another  means  of  producing  greater  resistance  on  one  side  of  the 
dental  arch  than  we  have  on  the  other  is  to  employ  a  perpendicular 


Fig.  566. — Perpendicular  tube  to  produce 
stationary  anchorage  on  molar  in  unilateral 
buccal   expansion. 


Fig.    567. — Parallel    tube    to    allow    tipping    of 
molar   in   unilateral   buccal    expansion. 


tube  on  one  side,  as  shown  in  Fig.  566  and  a  horizontal  tube,  as  shown 
in  Fig.  567.  The  perpendicular  tube  prevents  the  molar  from  moving 
unless  it  is  carried  bodily,  and  the  horizontal  tube  allows  tipping  of 
the  molar. 

After  the  upper  arch  was  expanded  to  the  proper  size,  and  the  teeth 
on  the  right  side  brought  to  their  proper  position,  they  were  retained 
by  the  retention  as  shown  in  Figs.  564  and  565. 

As  there  is  nothing  of  particular  interest  about  the  lower  arch,  the 
treatment  will  not  be  considered  here. 

By  looking  at  the  right  and  left  sides  of  the  case  shown  in  Fig.  568, 
it  will  be  seen  that  on  the  right  side  there  is  a  slight  mesial  tendency  of 
the  lower  teeth,  but  they  are  not  beyond  the  influence  of  the  cusp, 
and  the  case  is  therefore  classed  as  neutroclusion,  or  Class  I.    The  left 


406 


PRACTICAL    ORTHODONTIA 


side  shows  a  normal  mesio-distal  relation  of  the  molars  and  the  lower 
arch  is  short  on  that  side  owing  to  the  early  loss  of  the  second  de- 
ciduous molar,  which  has  permitted  the  space  intended  for  the  sec- 
ond premolar  to  close.  Looking  at  the  front  view  of  Fig.  568,  and 
the  left  side  of  Fig.  568,  it  will  he  seen  that  the  maxillary  left  in- 
cisor is  in  lingual  occlusion  to  such  an  extent  that  it  is  lingual  to  the 
mandibular  teeth.  In  order  to  get  this  tooth  into  its  proper  position, 
it  is  necessary  to  adiusl   the  expansion  arch  in  the  same  manner  as 


Fig.     568. — Neutroclusion,    or    Class    I,    case.     Impacted     mandibular    left     second    premolar    and 
maxillary  left  lateral  incisor  in  linguoversion  to   mandibular. 


described  in  other  cases.  The  arch  is  adjusted  so  that  it  stands  away 
from  the  teeth  slightly,  as  a  general  expansion  is  needed.  The  pre- 
molars are  ligated  to  the  arch,  as  are  the  incisors.  A  spur  should 
be  soldered  to  the  arch  directly  in  front  of  the  left  central  incisor 
so  as  to  prevent  the  central  from  drifting  to  the  left  as  it  is  carried 
forward.  After  the  arch  is  expanded  slightly  and  the  anterior  teeth 
carried  forward,  a  ligature  is  placed  on  the  left  lateral  and  it  is  car- 
ried labially  over  the  mandibular  anterior  teeth.     It  has  often  been 


TREATMENT    OF    CASES 


407 


suggested  that  a  gag  or  some  device  be  put  011  the  teeth  to  open  the 
bite  while  the  teeth  are  being  carried  from  lingual  to  normal  occlu- 
sion. The  author  has  never  found  this  necessary  in  his  practice. 
The  lower  arch  will  have  to  be  expanded  in  all  regions.     In  addition 


Fig.  369. — Front  view,  showing  upper  and  lower  arches. 


Fig.  570. — Spur  and  long  ligature  is  shown  on  left  side  to  move  canine  and  premolar  forward  to 
make  room   for  impacted   second  premolar. 


408  PRACTICAL   ORTHODONTIA 

to  that,  it  will  be  necessary  to  carry  the  left  premolar,  canine  and 
incisors  forward  to  make  room  for  the  impacted  second  premolar. 
The  lower  expansion  arch  is  adjusted  so  as  to  exert  force  on  all  of 
the  teeth  to  carry  them  buccally  and  labially.  The  relation  of  the 
expansion  arch  to  the  teeth  is  shown  in  Fig.  569.  The  expansion 
arch  must  be  made  wide  in  the  canine  region,  as  it  is  necessary  to  ex- 
pand the  dental  arch  a  great  deal  in  order  to  make  room  for  the  in- 
cisors. The  canines  are  moved  buccally  before  any  attempt  is  made 
to  bring  the  lower  right  lateral  forward.  The  mesial  movement  of  the 
left  mandibular  premolar  and  canine  is  accomplished  by  the  use  of  a 
long  wire  ligature  that  engages  the  premolar  and  canine,  and  is 
twisted  in  front  of  a  spur  that  has  been  soldered  to  the  arch  directly 
mesially  to  the  canine.     This  spur  is  attached  by  soft  solder  and  is 


Fig.   571.  Fig.    572. 

Fig.  571. — Intermaxillary  rubber  placed  distal  to  molar  tube  to  prevent  molar  from  moving 
distally,  as  the  nut  on  arch  is  screwed  distally  to  carry  anterior  teeth  forward  to  make  room 
for  impacted  premolar. 

Fig.  572. — Intermaxillary  rubber  placed  on  intermaxillary  hook,  which  is  mesial  to  nut  on 
lower  arch,  for  the  purpose  of  moving  lower  teeth  forward.  No  forward  force  is  exerted  on 
lower  molar  with  this  plan   of  attachment. 

made  by  twisting  a  ligature  wire  around  the  arch  after  the  manner 
described  in  the  making  of  spurs.  Fig.  570  illustrates  how  this  long 
ligature  is  placed  on  the  arch.  It  will  also  be  seen  that  there  is  an- 
other ligature  on  the  canine,  used  for  expansion.  After  this  long 
ligature  is  twisted  tight  around  the  premolar  and  canine,  the  teeth 
are  carried  forward  by  tightening  the  nut  on  the  expansion  arch.  This 
gives  the  same  movement  to  the  teeth  that  would  occur  with  a  jack- 
screw.  It  must  be  remembered  that  as  much  force  is  being  exerted 
upon  the  molar  as  upon  the  premolar,  canine  and  anterior  teeth. 
Very  often  the  lower  molar  will  be  displaced  distally,  in  which  case 
it  will  be  necessary  to  enlist  intermaxillary  anchorage  in  order  to  hold 
it  in  the  proper  position,  or  to  restore  it  to  its  normal  position  if  it 
has  been  displaced.  In  this  instance  intermaxillary  anchorage  will 
be  used  by  placing  an  intermaxillary-hook  on  the  upper  arch  in  the 


TREATMENT   OF    CASES  409 

region  of  the  upper  canine,  and  adjusting  a  rubber  from  it  to  the 
distal  portion  of  the  tube  on  the  lower  molar  band.  (Fig.  571.)  Some 
have  placed  an  intermaxillary-hook  on  the  lower  arch  just  in  front 
of  the  nut  on  the  left  side  and  attached  the  rubber  from  the  hook 
fastened  to  the  upper  arch  to  the  hook  on  the  lower  arch.  This  will 
prevent  any  forward  pull  upon  the  molar.  Where  the  intermaxillary 
rubber  is  used  from  the  upper  hook  to  the  distal  portion  of  the  lower 
band,  the  forward  pull  of  the  rubber  is  counteracted  by  the  backward 
push  of  the  nut  on  the  expansion  arch,  and  if  these  forces  are  kept 


Fig.    573. — Front   view    of    completed   case    shown    in    Fig.    568. 

balanced  the  molar  will  not  move  at  all.  Should  the  molar  be  moved 
distally  before  it  is  discovered  that  the  anterior  teeth  are  causing  the 
molar  to  be  displaced,  a  rubber  is  used  that  is  strong  enough  to  pull 
the  molar  and  lower  anterior  teeth  forward.  The  different  attach- 
ments for  this  use  of  intermaxillary  anchorage  are  shown  in  Figs. 
571  and  572. 

During  the  treatment  of  this  case,  the  second  left  lower  premolar 
came  into  position.  The  eruption  of  this  tooth  maintains  the  proper 
mesio-distal  relation  of  the  lower  teeth  on  the  left  side  (Fig.  573). 
The  upper  teeth  were  retained  by  placing  a  band  on  the  upper  lateral 
incisor  with  a  spur  on  the  labial  side  that  embraced  the  central  incisor 


410  PRACTICAL    ORTHODONTIA 

and  canine  (Fig.  574).  No  other  retainer  was  placed  on  the  upper 
teeth,  for  with  the  long  cusps  it  was  impossible  for  the  upper  arch  to 
narrow  unless  the  lower  one  did  so  first.  The  lower  arch  was  retained 
by  placing  bands  on  the  lower  canines  and  by  shaping  a  wire  to  fit  the 
lingual  surfaces  of  the  lower  molar.    This  lingual  arch  should  be  made 


Fig.    574. — Upper   impression    was    made    before    retaining   appliance    was    placed    on    lateral. 


Fig.   575. — Lower  impression   was  made  with   retainer   on  teeth.     Lingual   bar  extended  to   molars. 

of  some  material  that  possesses  considerable  spring.  It  is  soldered  to 
the  lingual  surface  of  the  canine  bands  and  occupies  the  position  shown 
in  Fig.  575.  The  narrowing  of  the  mandibular  molars  is  prevented  by 
the  spring  of  the  lingual  bar,  and  the  pressure  can  be  increased  in  a 
buccal  direction  by  grasping  the  bar  distal  to  the  canine  band  with 
a  pair  of  pliers  and  bending  it  outward. 


TREATMENT    OF    CASES 


411 


Fig.   576.  Fig.   577. 

Figs.   576  and  577. — Eack  of  facial  development  produced   by   neutroclusion.      (Tanzey.) 


Fig.    578. — Malocclusion    of    patient    shown    in  Fig.    579. — Occlusion    of    teeth    after    treatment 

Figs.  576  and  577.     (Tanzey.)  of  case  shown  in  Fig.  578.      (Tanzey.) 


412 


PRACTICAL    ORTHODONTIA 


Neutroclusion,  or  Class  I,  cases  present  many  varieties  and  produce 
various  effects  on  the  facial  outlines,  which  have  been  considered  in  a 
previous  chapter.  Neutroclusion  cases  that  have  a  bunching  of  the 
teeth  as  Ave  have  just  described  produce  a  lack  of  development  of  the 
dental  region  of  the  face,  which  is  shown  in  Figs.  576  and  577.  The 
position  of  the  teeth  is  shown  in  Fig.  578.  The  proper  treatment  of 
the  malocclusion  resulted  in  the  condition  as  shown  in  Fig.  579.  The 
expansion  of  the  arches  is  shown  in  Fig.  580.  The  result  of  the  ex- 
pansion of  the  arches  and  of  the  placing  of  the  teeth  in  their  proper 
positions  produced  the  change  in  the  face,  which  is  shown  in  Figs. 
581,  582  and  583. 


Fig.   580. — Occlusal  view  before  and  after  treatment.      (Tanzey.) 


Mutilated  Cases  of  Class  I,  or  neutroclusion,  should  be  treated  with 
a  view  of  restoring  normal  occlusion  as  nearly  as  possible.  This  means 
that  some  artificial  substitute  should  be  placed  on  the  teeth  that  will 
take  the  place  of  the  missing  teeth  or  tooth.  Considerable  has  been  writ- 
ten on  "Compromise  Treatment,"  which  means  that,  in  those  cases 
that  have  been  mutilated,  some  method  is  followed  that  will  improve 
the  occlusion  but  will  not  tend  to  produce  normal  occlusion.  The 
compromise  method  should  only  be  attempted  by  the  experienced  or- 
thodontist. 

It  has  long  been  recognized  that  one  of  the  most  troublesome  ques- 


TREATMENT    OF    CASES 


413 


Fig.   581. 


I  ^V'A 


Fig.   582. 


Fig.  583. 

Figs.    581,    582    and   583. — Improved    facial    expression    produced    by    the    correction    of    the   mal- 
occlusion present  in  Figs.  576  and  577.     (Tanzey.) 


414  PRACTICAL   ORTHODONTIA 

tions  in  the  correction  of  malocclusion  of  the  teeth  is  found  in  the 
treatment  of  those  cases  complicated  by  missing  teeth. 

If  one  will  go  hack  through  the  dental  literature  a  number  of  years 
he  will  find  that  this  question  has  been  discussed  in  several  different 
ways,  and  at  the  present  time  no  satisfactory  method  has  been  sug- 
gested that  can  be  followed  in  the  treatment  of  all  cases.  In  fact,  one 
of  the  greatest  troubles  that  seems  to  arise  in  considering  these  cases 
of  malocclusion  when  complicated  by  missing  teeth,  is  so  many  prac- 
titioners want  to  follow  a  fixed  rule  in  all  cases  rather  than  to  select 
a  treatment  which  is  best  suited  to  the  particular  case  in  hand. 

In  deciding  what  plan  of  treatment  is  to  be  followed  in  reference  to 
missing  teeth,  we  must  take  into  consideration  the  occlusion  and  es- 
thetic results,  as  we  find  them.  We  must  consider  what  the  result  is 
to  be  according  to  what  plan  of  treatment  is  followed  and  what  bene- 
fit it  will  be  to  the  occlusion  and  facial  outline.  We  must  remember 
that  any  plan  we  choose  will  not  give  an  ideal  result,  for  the  establish- 
ment of  an  ideal  occlusion  is  impossible  in  cases  complicated  by  missing 
teeth,  whether  we  replace  the  missing  tooth  with  an  artificial  substi- 
tute or  follow  some  plan  which  gives  a  compromise  occlusion,  based  upon 
the  masticating  efficiency  of  the  teeth.  After  considering  the  occlusion 
and  esthetic  conditions  as  we  find  them  and  carefully  considering  the 
changed  conditions  as  the  result  of  the  different  plans  of  treatment, 
we  are  ready  to  consider  some  of  the  other  factors  which  may  be  termed 
difficulties  encountered  in  the  treatment  of  the  case.  As  we  have  said 
one  of  the  first  things  is  the  age  of  the  patient  and  the  condition  of  the 
■surrounding  tissues.  It  would  be  possible  to  institute  extensive  ortho- 
dontic treatment  in  a  child  and  move  teeth  a  great  distance  when  the 
surrounding  tissues  were  healthy,  while  in  an  adult  where  the  tissues 
were  not  healthy  we  would  not  attempt  such  extensive  movement.  In 
a  young  person  where  the  teeth  have  not  been  worn  by  mastication  it 
might  be  advisable  to  change  molar  and  premolar  relations,  mesio- 
distally,  where  the  abnormal  relation  has  been  produced  by  missing 
teeth;  while  in  an  older  person  where  use  had  worn  the  cusps  to  oc- 
clude in  the  abnormal  position  mesio-distally,  the  best  plan  would  be 
to  leave  the  molars  and  premolars  where  they  are. 

If  it  has  been  decided  that  the  missing  tooth  should  be  replaced  by 
an  artificial  one,  the  question  of  prosthetic  procedure  becomes  an  im- 
portant point.  In  considering  this  question,  we  can  only  do  so  from  the 
orthodontist's  standpoint,  and  may  not  agree  with  prosthetic  men.  We 
are  aware  that  the  profession  is  divided  upon  the  question  of  fixed  or 
removable  replacements.     In  reference  to  removable  replacements,  they 


TREATMENT    OP    CASES  415 

must  be  of  such  a  nature  as  to  retain  the  normal  approximal  contact  of 
all  the  teeth.  They  must  have  the  proper  occlusion  and  not  injure  the  soft 
tissue.  In  reference  to  fixed  replacements  of  missing  teeth,  they  must 
be  attached  at  both  the  mesial  and  distal  sides.  It  must  be  an  attach- 
ment that  will  mutilate  the  abutment  teeth  as  little  as  possible.  This 
means  in  most  cases  the  use  of  some  form  of  inlay  attachment.  The 
attachment  should  be  made  without  destroying  the  pulp  of  the  tooth ; 
it  should  be  made  in  such  a  manner  as  to  allow  of  physiologic  tooth 
movement,  under  the  stress  of  mastication,  when  possible.  As  a  result 
of  the  difficulties  encountered  in  replacing  missing  teeth,  no  one  plan 
exactly  fulfills  all  requirements. 

In  taking  up  the  question  of  orthodontic  cases  complicated  by  miss- 
ing teeth,  we  can  also  consider  the  cases  according  to  the  tooth  that  is 
missing,  whether  it  is  an  incisor,  canine,  premolar  or  molar. 

In  speaking  of  missing  incisors,  the  condition  of  the  malocclusion  and 
the  age  of  the  patient  must  be  taken  into  consideration  before  we  decide 
whether  it  would  be  the  most  advantageous  thing  to  open  up  the  space 
so  that  an  artificial  tooth  could  be  placed.  If  we  have  a  patient  with 
the  incisor  missing  either  congenitally  or  the  result  of  an  accident  or 
disease  in  which  all  of  the  other  teeth  occupy  practically  a  normal  posi- 
tion both  approximally  and  occlusally,  as  a  general  rule,  the  only  thing 
to  do  would  be  to  use  an  artificial  substitute.  After  the  space  has  been 
opened  and  it  has  been  decided  to  place  an  artificial  substitute,  the 
question  of  procedure  from  that  point  on  becomes  one  of  more  or  less  im- 
portance. The  first  question  is,  How  are  you  going  to  place  an  artificial 
substitute?  To  answer  this  question  in  a  general  way  we  believe  that  any 
plan  that  is  followed  must  be  a  plan  whieh  will  support  the  artificial 
tooth  on  both  mesial  and  distal  sides.  In  other  words,  no  artificial  tooth 
which  cannot  be  supported  by  two  teeth  should  be  placed  in  an  ortho- 
dontic case.  In  making  this  statement  we  recognize  the  fact  that  we  are 
going  to  be  criticized  because  in  doing  this  it  will  be  necessary  to  mu- 
tilate the  two  approximating  teeth.  In  mutilating  these  teeth  we  are 
aware  of  the  fact  that  we  will  be  confronted  by  the  question  of  whether 
or  not  we  shall  remove  the  pulp.  This  particular  question  will  be  an- 
swered very  emphatically,  both  ways,  depending  on  whether  the  crown 
and  bridge  man  is  one  who  believes  in  "vital"  attachments  or  one  who 
believes  in  "devitalizing."  We  recognize  the  argument  on  both  sides  of 
the  question,  both  from  the  standpoint  of  the  crown  and  bridge  man 
and  from  the  standpoint  of  the  orthodontist,  as  well  as  the  efficiency 
from  the  standpoint  of  the  patient ;  it  has  seemed  to  the  author  that  the 
most  important  thing  to  consider  in  orthodontic  cases  where  missing  in- 


416  PRACTICAL    ORTHODONTIA 

cisors  are  being  replaced  is  the  question  of  esthetics  and  the  maintaining 
of  the  occlusion  of  the  other  teeth.  The  question  of  strength  and  mas- 
ticating efficiency  becomes  the  third  feature  of  consideration.  In  other 
words,  orthodontic  patients,  who  have  artificial  teeth  in  the  anterior 
part  of  their  mouths  should  be  instructed  that  those  teeth  will  not 
stand  a  large  amount  of  mastication  and  must  be  favored.  The  reason 
for  this  advice  is  that  if  the  case  is  favored  and  they  are  advised  that  a 
large  amount  of  mastication  cannot  be  done  on  those  teeth  it  makes 
possible  an  attachment  which  is  better  from  an  esthetic  standpoint,  al- 
though it  possesses  less  strength.  Working  from  the  standpoint  of  es- 
thetics in  the  maintaining  of  the  occlusion  of  the  remaining  teeth,  we 
believe  the  best  plan  of  attachment  is  not  to  "devitalize"  the  abutment 
teeth,  but  to  place  the  missing  tooth  by  means  of  inlays  which  can  be 
done  without  endangering  the  pulp  of  the  natural  teeth. 

In  attaching  artificial  incisors  by  means  of  inlays,  the  inlays  must 
be  made  and  placed  in  such  a  position  as  not  to  endanger  the  pulp.  In 
a  great  many  cases  owing  to  the  close  occlusion  between  the  maxillary 
and  mandibular  incisors  some  form  of  iridio-platinum  spur,  the  ends 
of  which  are  attached  to  the  inlay,  can  be  used  to  strengthen  the  at- 
tachment of  the  artificial  tooth.  These  inlay  attachments,  being  neces- 
sarily made  small  so  as  to  avoid  the  pulps  of  the  teeth,  do  not  offer  as 
much  strength  as  do  the  artificial  teeth  replaced  by  means  of  a  post. 
However,  the  patient  must  be  cautioned  that  an  artificial  tooth  is  in- 
serted primarily  for  esthetic  reasons  and  will  not  stand  a  large  amount 
of  mastication.  They  must  also  be  told  that  it  is  more  essential  that  they 
have  a  good  appearing  artificial  tooth,  withput  the  possibility  of  caus- 
ing discoloration  in  the  attached  tooth  which  may  occur  if  the  pulp  is 
removed  than  it  is  to  have  one  extremely  rigid  which  does  not  look 
so  well  and  which  may  result  in  discoloration  and  disease  of  the  at- 
tached teeth. 

It  is  better  for  the  patient  to  have  the  artificial  tooth  reattached  or 
recemented  several  times  a  year  than  it  is  to  run  the  risk  which  may 
come  from  destroying  a  pulp.  The  one  principal  objection  in  making 
attachments  for  artificial  teeth  by  means  of  inlays  in  the  anterior  portion 
of  the  mouth,  is  that  owing  to  the  small  amount  of  tooth  surface  in- 
volved it  is  very  difficult  to  make  an  attachment  which  fulfills  the  phys- 
iologic conditions  of  mastication.  It  is  very  difficult  to  attach  the 
artificial  tooth  in  such  a  manner  that  the  abutting  tooth  can  respond 
under  the  stress  of  mastication  which  is  one  of  the  physiologic  factors. 
Even  though  physiologic  tooth  movement  cannot  be  obtained  in  the 
anterior  portion  of  the  mouth  as  satisfactorily  as  in  the  case  of  molars 


TREATMENT   OF    CASES 


417 


and   premolars,  I  believe  the  inlay  attachment  offers  better  conditions 
than  any  plan  which  has  been  followed  heretofore. 

In  cases  which  involved  missing  maxillary  laterals,  I  believe  a  more 
efficient  result  from  the  standpoint  of  occlusion  and  mastication  and 
even  probably  from  the  standpoint  of  esthetics  can  be  obtained  without 
opening  up  the  space  for  the  lateral.  I  refer  to  those  cases  which  some- 
times have  been  classified  according  to  Angle's  plan,  as  a  subdivision 


Fig.   584.      (Gifford.) 


Fig.   585.      (Gifford.) 


of  Class  II,  which  really  are  not  distoclusion  eases,  but  which  are  cases 
in  which  the  maxillary  molars,  premolars,  and  canine  because  of  loss 
of  approximal  contact,  have  taken  a  mesial  position  in  regard  to  the 
mandibular  teeth.  In  other  words,  we  find  the  mesio-buccal  cusp  the 
maxillary  molar  occluding  between  the  mandibular  first  molar  and 
second  premolar,  with  the  maxillary  first  premolar  occluding  between 


418 


PRACTICAL    ORTHODONTIA 


the  mandibular  first  premolar  and  canine  and  the  maxillary  canine  oc- 
cluding in  the  position  of  the  maxillary  lateral.  In  order  to  open  up 
this  space  for  this  missing  lateral  it  would  be  necessary  to  move  distally 
all  the  molars  and  premolars  and  canine  upon  that  side.  This  move- 
ment could  be  accomplished,  but  it  involves  a  long  period  of  orthodon- 


Fig.   586.      (Gifford.) 


Fig.   587.      (Gifford.) 

tic  procedure  which  in  a  patient  past  the  age  of  twelve  would  be  a  very 
questionable  thing  to  do. 

In  order  to  establish  anything  like  an  efficient  occlusion  such  as  we 
have  in  the  beginning  a  bodily  movement  of  all  those  teeth  would  be 
necessary  which,  while  possible,  would  involve  a  long  period  of  time  and 
would  result  in  an  occlusion  which,  from  a  point  of  masticating  effi- 


TREATMENT   OF    CASES  419 

ciency,  would  be  no  more  satisfactory  than  the  one  which  we  had  in  the 
beginning.  We  believe  in  a  large  number  of  those  cases  a  much  more 
efficient  occlusion  can  be  obtained  and  a  dental  apparatus  produced 
which  will  be  more  serviceable  to  the  patient  by  leaving  the  maxillary 
molars  and  premolars  on  the  abnormal  side  in  the  mesial  position  and 
correcting  whatever  other  malocclusions  may  be  present.  One  of 
the  reasons  a  better  occlusion  of  the  molars  and  premolars  from  a  mas- 
ticating standpoint  can  be  obtained  by  leaving  them  alone  is  that  the 
cusps  have  worn  to  fit  in  that  position.  If  the  patient  had  never  mas- 
ticated sufficiently  to  wear  the  teeth,  this  plan  would  not  be  so  advisa- 
ble. After  the  malocclusion  is  corrected,  the  maxillary  canine  which 
is  in  the  place  of  the  lateral  can  be  ground  down  and  made  to  resemble 
a  lateral  as  nearly  as  possible  (Figs.  584,  585,  586  and  587). 

I  admit  that  this  plan  does  not  give  the  most  ideal  esthetic  re- 
sult, but  gives  a  much  more  efficient  occlusion  and  one  which  is  going 
to  be  much  more  serviceable  for  the  patient  than  would  be  obtained  by 
the  long  orthodontic  procedure  of  moving  the  molars,  premolars,  and 
canine  distally  and  then  placing  an  artificial  lateral. 

When  we  consider  the  question  of  replacing  canines  which  are  seldom 
missing  except  as  the  result  of  accident  or  disease,  we  again  must  take 
into  consideration  the  conditions  present  in  that  particular  case.  If 
we  had  a  case  of  malocclusion  in  a  comparatively  young  patient  in 
which  all  of  the  remaining  teeth  occupied  a  normal  mesio-distal  relation 
to  the  occluding  teeth,  as  a  general  rule,  we  would  say  the  maxillary 
canines  should  be  replaced  by  an  artificial  substitute.  This  artificial 
substitute  should  be  anchored  to  both  the  premolar  and  lateral,  at 
least  the  anterior  end  of  the  mesial  surface  of  the  artificial  canine  should 
have  some  sort  of  support  upon  the  lateral  incisor.  This  support  should 
be  made  in  such  a  manner  as  to  maintain  normal  proximal  contact  and 
prevent  the  lateral  incisor  from  slipping  past  the  artificial  canine  la- 
bially  or  lingually.  We  also  would  suggest  that  in  these  cases  an  inlay 
be  placed  in  the  lateral  which  would  be  cemented  in  place.  A  cavity 
or  groove  should  be  cut  in  the  inlay  for  the  reception  of  an  abutment  or 
spur  from  the  artificial  canine.  This  would  give  a  support  occlusal]}. 
buccally,  and  lingually  and  still  allow  for  a  certain  amount  of  move- 
ment between  the  artificial  tooth  and  the  canine  under  the  stress  of 
mastication  and  thereby  more  nearly  approach  physiologic  conditions. 
From  our  observation,  we  also  believe  that  in  the  replacement  of  a 
missing  canine  by  an  artificial  substitute,  such  attachments  should  be 
made  as  would  not  destroy  the  pulp  of  either  the  premolar  or  the  lateral. 

We  find  another  class  of  cases  in  which  the  canine  has  been  missing 


420  PRACTICAL   ORTHODONTIA 

congenitally  and  the  molars  and  premolars  on  that  side  have  come  for- 
ward until  the  premolar  occupies  the  position  intended  for  the  canine 
with  the  molars  and  premolars  one  cusp  mesial  to  normal.  In  such  con- 
ditions as  that,  we  helieve  it  would  he  much  better  not  to  open  up  the 
space  for  the  missing  canine,  but  to  leave  the  occlusion  as  it  has  been 
established  during  the  process  of  development  and  allow  the  first  pre- 
molar to  occupy  the  position  of  the  canine,  with  all  the  molars  and  pre- 
molars on  that  side  one  cusp  mesially.  Such  conditions  as  this  will 
give  just  as  good  an  esthetic  result  as  would  be  obtained  if  the  canine 
were  in  position,  for  the  first  premolar  has  probably  erupted  in  an  up- 
right manner  and  in  its  forward  position  the  crown  and  root  conse- 
quently fills  out  the  corner  of  the  face  the  same  as  a  normal  canine 
would.  The  occlusion  of  the  mesial  molars  and  premolars  have  probably 
worn  in  such  manner  as  to  make  an  efficient  occlusion  which  would  be 
just  as  good  from  a  masticating  standpoint  as  if  they  occupied  their 
normal  positions. 

The  question  of  missing  premolars,  maxillary  or  mandibular,  is  very 
much  the  same  and  has  to  be  considered  in  regard  to  the  age  of  the  pa- 
tient, the  extent  of  the  development  of  the  alveolar  process  or  growth 
of  the  jaws,  and  whether  the  tooth  is  congenitally  absent  or  has  been  lost 
as  a  result  of  accident  or  disease,  and  the  position  of  the  remaining 
teeth  from  an  occlusal  standpoint.  In  dealing  with  premolars  that 
are  congenitally  absent,  I  have  found  in  my  practice  the  ones  most  often 
missing  are  the  mandibular  second  premolars.  Because  of  this,  I  be- 
lieve it  is  a  good  plan  in  the  treatment  of  every  case  of  malocclusion  be- 
fore the  time  of  the  eruption  of  the  premolars  to  have  radiograms  made 
to  prove  whether  the  premolar  is  missing  or  present.  Therefore  in 
treating  a  case  of  malocclusion  in  which  we  find  the  mandibular  second 
premolar  is  absent,  I  believe  a  more  efficient  result  from  the  standpoint 
of  serviceable  occlusion  can  be  obtained  by  instituting  a  plan  of  treat- 
ment, which  will  move  the  mandibular  molars  forward  the  width  of  the 
premolar,  therefore,  establishing  a  mesial  occlusion  of  the  mandibular 
molars  with  the  maxillary  molars  and  closing  the  space  in  that  manner. 
Cases  treated  by  this  plan  prior  to  the  eruption  of  the  second  molars 
have  shown  that  the  first  molars  can  be  moved  forward  bodily  and  the 
second  molars  in  erupting  will  take  the  position  approximating  the 
first  molar.  This  plan  of  treatment  produces  the  normal  occlusion  of 
the  teeth  from  the  first  premolar  forward  and  the  mandibular  molar 
one  cusp  mesial.  The  masticating  efficiency  in  these  cases  is  far  superior 
to  those  in  which  a  missing  tooth  is  supplied  and  one  which  eliminates 
the  possibility  of  trouble  by  making  attachments  to  vital  teeth. 


TREATMENT    OF    CASES 


421 


The  congenital  absence  of  maxillary  premolars  before  the  eruption 
of  the  second  molar  should  be  handled  in  the  same  manner,  which  would 
consist  in  the  mesial  movement  of  the  maxillary  molars  to  close  the  space 
of  the  missing  tooth.  Fig.  588  is  a  case  described  by  Gifford  in  which 
the  second  maxillary  premolars  are  missing  on  both  sides.  The  patient 
was  ten  years  old.     By  the  use  of  intermaxillary  anchorage  the  maxil- 


Fig.   588.      (Gifford.) 


B. 


Fig.  589.      (Gifford.) 


lary  teeth  were  moved  forward  and  the  first  molar  made  to  occupy  a 
position  mesial  to  the  mandibular  first  molar.  Fig.  589  shows  the  treat- 
ment is  progressing  satisfactorily  and  the  occlusion  in  the  premolar  and 
canine  region  will  become  better  as  those  teeth  complete  their  eruption. 
In  cases  of  advanced  age,  after  the  eruption  of  the  second  molars,  where 
premolars  have  been  lost  as  a  result  of  accident  or  disease,  the  treatment 


422  PRACTICAL    ORTHODONTIA 

in  those  cases  would  depend  upon  the  condition  of  the  remaining  teeth. 
If  the  space  for  the  missing  premolar  has  been  closed  by  a  mesial  drift- 
ing of  the  teeth  distal  to  the  space,  in  the  majority  of  cases,  it  is  the 
most  advisable  plan  to  straighten  up  those  teeth  and  restore  their  use 
by  an  artificial  substitute.  In  cases  of  patients  of  advanced  age,  who 
because  of  extraction  have  lost  the  masticating  efficiency,  it  is  not  al- 
ways desirable  to  attempt  a  mesial  movement  of  the  molars  to  close  up 
the  space  made  by  the  premolars.  In  these  cases,  which  are  the  result 
of  mutilation,  something  must  be  done  to  improve  the  masticating  ap- 
paratus of  the  patient.  We  must  decide  what  is  going  to  give  the  most 
serviceable  results  with  the  least  possible  sacrifice  to  the  patient  and  if 
that  plan  is  followed,  which  involves  the  opening  up  of  the  spaces,  we 
then  have  to  use  artificial  substitutes  the  same  as  we  would  in  any  other 
class  of  cases  where  artificial  substitutes  are  recpiired  to  improve  the 
function  of  the  teeth.  Again,  in  the  replacement  of  the  premolars  the 
same  plan  must  be  followed,  the  replaced  tooth  must  be  attached  at 
both  ends.  Secondly,  we  believe  the  best  reults  can  be  obtained  by 
means  of  inlay  attachments  which  may  be  described  as  one  inlay  within 
another  or  by  some  form  of  removable  attachment  which  allows  for  in- 
dividual movement  of  the  teeth  during  mastieation. 

When  we  come  to  the  consideration  of  missing  molars  we  again  must 
be  controlled  by  the  age  of  the  patient  and  the  condition  of  the  maloc- 
clusion as  we  find  it.  The  author  believes  in  young  individuals,  in 
children  before  the  eruption  of  the  second  molar  where  the  first  molar 
has  been  hopelessly  diseased  and  has  to  be  sacrificed,  the  best  plan  of 
treatment  is  to  move  the  second  molar  forward  during  the  process  of 
its  eruption  and  make  it  occupy  the  space  formerly  occupied  by  the 
first  molar.  Various  cases  treated  by  this  plan  show  that  by  proper 
orthodontic  procedure  maxillary  and  mandibular  second  molars  can  be 
made  to  assume  the  position  of  the  first  molars,  in  an  upright  manner 
and  so  produce  a  very  serviceable  occlusion.  This  plan  of  treatment 
also  avoids  the  necessity  of  wearing  a  mechanical  retaining  device  to 
keep  the  space  made  vacant  by  the  missing  first  molar.  We  even  find 
another  class  of  cases,  after  the  eruption  of  the  second  molar  and  before 
the  eruption  of  the  third,  in  which  we  believe  it  is  advisable  to  bring  the 
second  molar  forward  and  close  the  space  made  vacant  by  the  first  mo- 
lar. We  refer  to  those  cases  in  which  the  radiogram  reveals  the  first 
molar  to  he  in  such  a  hopelessly  diseased  condition  that  the  question  of 
its  loss  wid  only  be  that  of  a  few  years.  We  believe  in  such  cases  it  is 
better  to  extract  the  first  molar  in  a  patient  twelve,  thirteen,  or  four- 
teen years  of  age  and  bring  the  second  molar  forward  bodily  to  close 


TREATMENT    OF    CASES 


423 


up  the  space  made  by  the  loss  of  the  first  molar.  Upon  eruption  the 
third  molar  will  take  its  position  behind  the  second  molar  and  will  gener- 
ally be  a  very  serviceable  tooth.  \Ve  have  observed  in  these  cases  where 
the  first  molars  are  lost  early,  the  third  molar  has  always  possessed  a  well 
developed  crown  and  become  a  very  serviceable  tooth  which  is  probably 
caused  by  relieving  the  pressure  and  bringing  the  second  molar  forward 
and  giving  the  third  molar  ample  room  to  develop. 

Fig.  590  shows  a  case  of  neutroclusion  complicated  by  the  loss  of  the 
permanent  molar.  It  was  treated  by  bringing  the  first  molars  forward 
and  closing  the  space,  thereby  making  a  more  serviceable  occlusion  than 
if  the  space  had  been  retained  fur  an  artificial  substitute.  Fig.  591 
shows  the  result  of  the  treatment. 


Fig.   590.       (Gifford.) 


Fig. 


(Gifford.) 


Fig.  592  shows  a  case  that  is  complicated  by  extraction.  The  man- 
dibular first  and  second  molars  and  second  premolars  below  were  ex- 
tracted. The  mandibular  third  molars  drifted  slightly  forward.  Owing 
to  the  loss  of  the  mandibular  molars  the  mandibular  anterior  teeth 
drifted  distally  until  the  lower  lip  was  caught  under  the  maxillary  an- 
terior teeth  and  those  teeth  were  forced  forward.  The  general  facial 
appearance  of  the  patient  would  suggest  distoclusion  or  Class  II,  but 
the  mesio-distal  relation  of  the  arches  shows  it  to  be  Class  I,  or  neutro- 
clusion. These  cases  become  so  extreme  that  they  demand  some  sort  of 
treatment,  and  it  is  to  show  that  something  can  be  done  for  these  un- 
fortunate patients  that  the  author  is  describing  this  case.    The  mandib- 


424  PRACTICAL    ORTHODONTIA 

ular  anterior  teeth  occlude  against  the  palatal  gums,  lingually  to  the 
maxillary  anterior  teeth.  This  condition  was  causing  a  great  amount 
of  irritation,  which  could  be  corrected  only  by  increasing  the  length  of 
the  molars  and  the  premolars. 

In  treating  this  case,  it  was  impossible  to  attach  bands  ou  the  lower 
molars  for  they  were  too  loose,  so  it  became  necessary  to  use  the  lower 
first  premolars  for  anchorage.  This  position  of  the  mandibular  teeth 
makes  it  necessary  to  move  all  of  the  lower  anterior  teeth  forward 
and  this  was  done  by  the  use  of  intermaxillary  anchorage.  In 
order  that  there  will  not  be  much  upward  pull  on  the  premolars,  a  bar 
is  soldered  to  the  premolar  band,  as  shown  in  Fig.  594,  which  extends 


Fig.   592. — A   mutilated   case   of   Class   I,    or   neutroclusion. 

backward  as  far  as  the  position  occupied  by  a  mandibular  first  molar. 
A  tube  to  support  the  end  of  the  arch  was  soldered  on  this  bar.  The 
distal  end  of  the  band  was  bent  lingually  so  as  to  form  a  "V,"  which 
engages  the  intermaxillary  rubber.  With  this  extension  bar  on  the 
premolar,  it  is  possible  to  use  a  regular  size  arch,  which  gives  a  greater 
range  of  spring  and  does  not  exert  much  occlusal  pull  on  the  premolars. 
The  upper  expansion  arch  was  adjusted  so  that  the  anterior  portion 
rested  against  the  maxillary  anterior  teeth,  buccally  to  the  canines  and 
premolars,  as  shown  in  Fig.  593.     The  nuts  on  the  upper  arch  did  not 


TREATMENT   OF    CASES 


425 


touch  the  tube  on  the  upper  molar  band,  for  all  of  the  force  of  the  rub- 
ber ligature  was  to  be  exerted  against  the  incisors.  Wire  ligatures  were 
placed  on  the  premolars  and  canines  so  as  to  move  them  buccally. 


Fig.  593. — Showing  upper  appliance  in  place. 


Fig.  594. — Showing  lower  appliance  in  place. 


The  backward  pull  of  the  intermaxillary  rubbers  against  the  maxil- 
lary anterior  teeth  was  also  reciprocated  against  the  lower  teeth.    As  the 


426 


PRACTICAL    ORTHODONTIA 


Fig.    595. — Side   view,    showing   intermaxillary    rubbers.      Compound    reciprocal    intermaxillary    an- 
chorage.    Note  position   of  nuts  on   upper  arch. 


Fig.   596. — Front  view,   showing  position   of   upper  arch. 


TREATMENT   OF    CASES 


427 


maxillary  incisors  moved  distally  faster  than  the  lower  teeth  moved  for- 
ward, when  the  maxillary  anterior  teeth  had  been  moved  to  their  proper 
position,  and  the  dental  arch  widened  the  proper  width,  the  nuts  on  the 
upper  expansion  arch  were  allowed  to  rest  against  the  bands  on  the  max- 
illary molars,  so  that  all  of  the  maxillary  teeth  were  pitted  against  all 
of  the  mandibular  teeth  (Figs.  595  and  596).  The  continued  use  of  the 
intermaxillary  rubbers  finally  moved  the  mandibular  teeth  to  their 
proper  position.  It  was  then  necessary  to  restore  the  missing  teeth.  In 
this  case  a  gold  plate  was  used.  The  improvement  of  the  facial  outline 
was  very  pleasing.     The  improvement  in  the  occlusion  of  the  teeth  is 


Fig.   597. — Completed   result  of  case   shown   in    Fig.    592. 


shown  in  Fig.  597.  Cases  of  this  type  are  not  attractive  to  some  opera- 
tors, and  many  practitioners  go  so  far  as  to  advise  against  treatment, 
but  these  unfortunate  people  have  a  right  to  some  relief,  and  if  properly 
handled,  very  satisfactory  results  can  be  obtained. 

The  retention  of  the  case  consisted  in  placing  an  accurately  fitting 
gold  plate  in  the  lower,  which  carried  properly  occluded  artificial 
teeth  with  proper  mesio-distal  contact.  This  plate  retained  the  lower 
teeth  in  their  proper  position.  No  retaining  appliance  was  put  on  the 
upper  teeth,  as  it  was  impossible  for  them  to  change  their  position 
owing  to  the  position  of  the  lower  lip  and  the  force  of  the  muscular 
pressure. 


428 


PRACTICAL    ORTHODONTIA 


Common  forms  of  neutroclusion,  or  Class  I,  cases  are  those  that  are 
mutilated  as  the  result  of  the  extraction  of  the  first  molars.  These 
patients  often  give  a  history  of  a  normal  occlusion  prior  to  the  time 
of  the  extraction  of  the  first  molars.     The  change  is  often  gradual  and 


Fig.   598. 


Fig.   599. 

Figs.    598    and    599. — Front   and    side-    view    of    malocclusion    caused    by    extraction    of    mandibular 

first  molars. 


TREATMENT   OP    CASES  429 

they  are  not  aware  of  the  trouble  that  is  resulting  until  it  is  brought 
to  their  attention.  In  the  ease  shown  in  Figs.  598  and  599,  which  was 
caused  by  the  early  loss  of  the  mandibular  first  molars,  the  teeth  grad- 
ually drifted  together  until  the  mandibular  second  molars  and  the  pre- 
molars were  in  contact  on  both  sides.  As  a  result  of  this  drifting,  none  of 
the  teeth  are  in  normal  occlusion.  The  lower  incisors  are  biting  against 
the  upper  gums,  and  to  remedy  this  condition  the  difficulty  presented 
was  to  open  the  space  for  the  missing  teeth  and  to  supply  an  artificial 
substitute. 

Very  often,  in  these  cases,  it  is  necessary  to  open  the  space  only  far 
enough  to  supply  a  tooth  half  the  size  of  the  molar,  as  that  is  sufficient 
in  some  cases  to  open  the  bite  far  enough  to  prevent  the  mandibular 
teeth  from  striking  the  upper  gums.     However,  it  must  be  remembered 


Fig.   600. — Position    of  tube   on   molar   band,   which    must   be   resoldered   so   as   to   assume   position 

shown   in   Fig.    601. 

that  it  is  always  necessary  to  move  the  lower  anterior  teeth,  or  rather 
the  teeth  anterior  to  the  missing  molars,  into  their  proper  position.  If 
the  proper  space  is  not  restored,  it  is  because  the  second  and  third  mo- 
lars are  not  moved  distally  to  their  proper  position,  for  the  teeth  ante- 
rior to  them  must  always  occupy  the  proper  mesio-distal  relation  to  the 
uppers. 

In  treating  these  cases,  it  is  necessary  to  move  the  molars  distally 
and  the  teeth  anterior  to  them  mesially.  Clamp  bands  are  placed  on 
the  second  molars,  and  owing  to  the  tipping  of  these  teeth  it  is  al- 
ways necessary  to  solder  the  tube  at  a  different  angle  from  that  which 
it  occupies  on  the  band  as  supplied  by  the  manufacturers.  Fig.  600 
shows  the  tipping  that  usually  is  encountered  in  these  eases,  and  plainly 
illustrates  the  position  that  the  tube  assumes  as  the  band  is  placed  on 


430  PRACTICAL   ORTHODONTIA 

the  tooth.  In  Fig.  C01  is  shown  the  position  to  which  the  tube  must  be 
changed.  In  aligning  the  tube,  the  anterior  part  of  the  tube  should  be 
so  placed  that  the  anterior  part  of  the  arch  rests  apically  to  the  gingival 
part  of  the  teeth,  as  shown  in  Fig.  602.  This  position  of  the  arch  is  nec- 
essary to  give  a  backward  and  upward  tipping  of  the  molar,  produced 
by  springing  the  arch  ocelusally  and  wiring  the  anterior  portion  of  the 
arch  to  the  anterior  teeth.  The  effect  of  this  action  upon  the  molars  is 
shown  in  Fig.  603.  The  side  view  of  the  appliance  is  shown  in  Fig.  604. 
Spurs  are  placed  on  the  lower  arch  mesially  to  the  canines  for  the  pur- 
pose of  using  the  long  ligatures  to  bring  the  premolars  and  canines  for- 
ward. The  ligatures  on  the  anterior  teeth  carry  them  forward  as  the 
nuts  on  the  arch  are  tightened.  The  tightening  of  the  nut  exerts  a  back- 
ward force  on  the  molars  and  a  forward  force  on  the  anterior  teeth. 


Fig.   601. — Position  of  arch,  which  is  sprung  up  to  tip  molar  backward. 

Under  ordinary  conditions  the  anterior  teeth  would  move  more  rapidly 
than  the  molars,  but  it  must  be  remembered  that  the  molars  have  a  tip- 
ping force  exerted  on  them  by  the  spring  of  the  arch.  If  the  molars  do 
not  move  distally  as  fast  as  they  should,  and  there  is  danger  of  moving 
the  anterior  teeth  too  far,  intermaxillary  anchorage  can  be  used,  with 
the  rubber  running  from  the  tube  on  the  maxillary  molar  band  to  an  in- 
termaxillary hook  on  the  lower  expansion  arch  opposite  the  canine.  It 
would  be  necessary  to  adjust  an  alignment  wire  on  the  upper  teeth, 
which  was  not  used  in  this  case,  if  intermaxillary  anchorage  was  em- 
ployed. The  upper  arch  required  expansion  only  in  the  canine  and 
premolar  region,  and  this  was  accomplished  by  placing  plain  bands 
on  the  canines  to  which  was  soldered  a  lingual  spur  that  rested  against 
the  maxillary  first  premolar.  On  the  labial  surface  of  the  canine  band 
was  soldered  a  horizontal  tube  that  received  the  18-gauge  wire  that 


TREATMENT   OF    CASES 


431 


supplied  the  expansive  force.  The  appliance  is  shown  in  Figs.  604, 
005,  606,  and  607. 

After  the  space  has  been  provided,  the  retention  will  consist  in  re- 
storing the  missing  tooth  by  some  means  as  indicated  in  crown  and 
bridge  work.  The  position  of  the  anterior  teeth  can  be  retained  by 
any  of  the  retaining  devices  mentioned  heretofore  that  meet  the  re- 
quirements of  the  case. 

In  the  treatment  of  mutilated  cases,  or  other  cases  where  there  are 
missing  teeth,  one  of  the  unsatisfactory  problems  is  the  replacing  of 
the  missing  tooth  with  an  artificial  substitute.  The  replacement  of 
the  missing  tooth  with  the  artificial  tooth  presents  more  problems  than 
was  at  first  imagined.  In  order  for  the  replaced  tooth  to  be  of  the 
greatest  use,  it  must  be  so  made  as  to  present  the  proper  masticating 


Fig.   602. 


Fig.   603. 


Fig.   602. — Showing   gingival   position   of  arch,   which   must   be   sprung  occlusally,   as   shown   In- 
dotted   line,   and   wired   to   anterior   teeth   to    tip   molar   distally. 

Fig.    603. — Dotted   tooth    form   illustrates   result    of   action   as   outlined   in   occlusion. 


surface  and  also  to  have  the  proper  mesio-distal  diameter.  The  fact 
that  a  great  many  methods  make  necessary  the  mutilation  of  the  teeth 
to  which  the  artificial  tooth  is  attached,  has  caused  many  to  try  to 
avoid  the  use  of  artificial  substitutes  more  than  they  have  in  times 
past.  In  those  cases  in  which  the  first  molars  are  lost  early,  it  is 
possible  to  move  the  second  molars  forward  in  an  upright  position 
and  to  close  the  space  and  make  the  second  molar  take  the  place  of  the 
first.  It  is  true  that  the  second  and  first  molars  are  not  of  the  same 
shape,  but  by  closing  the  space  after  the  manner  suggested,  we  avoid 
the  necessity  of  mutilating  the  teeth  for  the  attachment  of  artificial 
teeth  and  do  not  compel  a  young  patient  to  go  through  life  with  some 
form  of  artificial  tooth  in  his  mouth.  However,  in  the  cases  in  which 
the  remaining  teeth  are  moved  to  close  the  vacant  spaces,  there  must 


432 


PRACTICAL    ORTHODONTIA 


Fig.   604. — Appliance  as  first  placed  on   molars.      Side  view. 


Fig.    605. 


-Shows    model    with    lower   appliance    in    place.      Small    arch    was    placed    on    canines    to 
expand   upper  arch   in   canine    region. 


TREATMENT    OF    CASES  433 

be  a  careful  diagnosis,  and  the  case  must  be  selected  that  is  suitable 
for  such  treatment.  The  case  shown  in  Fig.  604  could  be  benefited 
only  by  opening  the  space,  as  the  teeth  posterior  and  anterior  to  the 


Fig.   606. — Occlusal  view   of   upper  appliance   to  expand   canines   and  premolars. 


Fig.    607. — Model    of    mandibular    teeth    with    appliance    adjusted,    showing    how    space    has    been 

made   for   extracted   tooth. 


missing  tooth  had  tipped  to  such  an  extent  that  the  mandibular  teeth 
were  impinging  against  the  upper  gum.  In  young  patients  it  is  possible 
to   bring   the   second   molars   forward   and   produce   more   satisfactory 


434  PRACTICAL    ORTHODONTIA 

results  where  the  first  molars  are  missing  than  to  attempt  to  maintain 
the  space  and  insert  an  artificial  substitute. 

In  a  great  many  cases  of  neutroclusion,  it  is  possible  to  use  the 
lingual  wire,  which  makes  an  appliance  that  is  less  bulky  and  con- 
spicuous than  the  labial  wire. 

Fig.  609  shows  the  front  view  of  the  model  of  a  patient  six  years  of 
age,  with  an  underdeveloped  upper  and  lower  arch.  Fig.  610  shows 
the  occlusal  view  of  the  upper  arch  with  a  bunching  of  the  deciduous 
incisors;  a  lack  of  development  between  the  maxillary  canines.  There 
is  also  a  crowding  of  the  mandibular  permanent  incisors,  which  can  be 
seen  in  Fig.  609.    This  crowding  is  the  result  of  the  lack  of  development 


Fig.   608. — Made  during  treatment.      Compare  with   Fig.   598. 

of  the  lower  arch,  which  in  turn  is  also  retarded  by  the  lack  of  de- 
velopment of  the  upper  arch.  The  lingual  alignment  wire  was  placed 
on  the  maxillary  teeth,  as  shown  in  Fig.  611,  with  bands  upon  the  decid- 
uous molars.  By  pinching  the  lingual  alignment  wire  in  the  incisal  por- 
tion, the  angles  that  rest  against  the  deciduous  canines  are  carried  away 
from  each  other,  resulting  in  expansion  in  the  canine  region,  which 
will  also  cause  some  expansion  of  the  molars.  As  the  upper  dental 
arch  is  widened,  thereby  giving  more  room  for  the  lower  arch,  the 
lower  arch  developed  and  the  teeth  were  forced  buccally  by  the  action 
of  the  tongue  assisted  by  the  force  of  the  inclined  plane  of  the  mandib- 


TREATMENT    OF    CARES 


435 


ular  teeth  with  the  maxillary  permanent  and  deciduous  molars.  In  tak- 
ing cases  at  this  age  it  is  not  always  necessary  to  place  an  appliance  on 
both  arches  as  the  lingual  arch  is  used  only  on  the  maxillary  teeth. 
By  pinching  the  lingual  wire  the  development  of  the  upper  dental  arch 
occurred,  as  is  shown  in  Figs.  Gil  and  612,  and  the  appliance  is  much 
less  conspicuous  than  many  other  appliances  would  be  and  causes  little 


Fig.    609. — Front    view    of    case    showing   lack    of    development.      (Lourie.) 


Fig.    610. — Occlusal   view    showing   lack    of    de- 
velopment of   upper  arch.      (Lourie.) 


Fig.  611. — Upper  arch  with  lingual  wire  in 
place.  Compare  with  Fig.  610  for  amount  of 
development   obtained.      (Lourie.) 


annoyance  to  the  patient.     The  use  of  the  lingual  alignment  wire  in 
neutroclusion  cases  offers  many  possibilities. 

The  lingual  wire  soldered  to  the  molar  bands  can  also  be  used  suc- 
cessfully in  cases  of  neutroclusion  with  the  canines  in  inf ra-labioversion. 
Fig.  613  shows  the  front  view  of  such  a  case.  Bands  were  made  for  the 
first  molar  and  a  19'-gauge  lingual  wire  was  fitted  to  rest  against  the 
premolars  and  lateral  incisors.  In  the  beginning  of  the  treatment  the 
lingual  wire  did  not  touch  the  central  incisors,  as  it  would  be  brought 
into  contact  with  them  when  the  arch  was  expanded  and  the  laterals 


436 


PRACTICAL    ORTHODONTIA 


moved  forward.  By  pinching  the  lingual  wire  with  the  wire-stretch- 
ing pliers  in  the  region  between  the  canines,  the  premolars  and  molar 
region  would  he  expanded.  By  pinching  in  the  premolar  region  the 
lingual  wire  would  he  lengthened  and  the  incisors  carried  forward. 
Fig.  614  shows  the  occlusal  view  of  the  case  and  the  position  of  the 
lingual  wire.     It  will  be  seen  that  there  are  finger  springs  soldered  to 


Fig.    612.— Front   view   showing   development   as    result    of   use    of   lingual   arch.      Compare   with 

Fig.   614.      (Lourie.) 


Fig.  613. 


Fig.  614. 


the  lingual  wire  extending  labially  between  the  premolar  and  canine, 
and  they  are  bent  gingivally  to  engage  the  labio-gingival  portion  of  the 
canine.  These  finger  springs  are  made  from  22-gauge  spring  gold. 
Fig.  615  shows  the  front  view  of  the  appliance  and  the  appearance  of 
the  finger  springs  over  the  canines.  These  canine  finger  springs  can  be 
adjusted  so  as  to  exert  a  linguo-occlusal  pressure  on  the  canines  and 
cause  them  to  assume  the  position  shown  in  Fig.  616.     The  same  appli- 


TREATMENT   OF    CASES 


437 


ance  was  used  on  the  lower  without  the  canine  finger  springs.  This 
gives  a  very  compact  and  inconspicuous  appliance  and  if  one  has  mas- 
tered the  technique  of  using  the  wire-stretching  pliers  and  bending  fin- 
ger springs,  it  is  second  to  none. 

A  complication  often  found  in  neutroclusion  cases  is  that  of  impacted 


Fig.   615. 


Fig.   616. 


teeth.  Any  tooth  may  be  impacted  in  either  set  and  the  treatment  will 
depend  upon  other  conditions  present.  In  some  instances  the  impac- 
tion of  the  permanent  tooth  is  caused  by  an  encysted  supernumerary 
tooth  and  in  others  the  bone  overlying  the  erupting  tooth  does  not  ab- 
sorb and  seems  to  be  dense.  We  often  find  deciduous  molars  become 
impacted  during  the  eruption  of  the  permanent  molars  to  such  an  ex- 


438 


PRACTICAL    ORTHODONTIA 


tnit  thai  they  become  imbedded  in  the  gum  and  require  some  treatment 
to  stimulate  the  proper  development  of  the  arch  in  that  region.  Fig. 
617  shows  such  a  case.  Tbe  appliance  consisted  of  a  band  to  fit  the 
impacted  deciduous  molar  which  was  made  from  a  measurement  ob- 
tained from  the  deciduous  molar  on  the  opposite  side.  In  order  to 
afford  a  stronger  attachment  for  the  cement  a  cusp  was  wedged  for  the 
band  which  made  a  crown  to  fit  over  the  occlusal  surface  of  the  impacted 
tooth.  The  first  deciduous  molar,  canine  and  incisors  were  utilized  as 
anchor  teeth,  by  easting  a  silver  crib  to  fit  over  them  as  shown  in  Fig. 
618.  Half  round  tubes  were  soldered  on  the  buccal  and  lingual  surface 
of  the  crown  that  was  made  for  the  impacted  deciduous  molar  for  the 
purpose  of  receiving  the  ends  of  the  spring  wires  that  were  soldered  to 


Fig.   017.      (Richardson.) 


Fig.    618.      (Richardson.) 


the  crib  that  fits  the  anterior  teeth.  When  the  two  parts  of  the  appli- 
ance are  cemented  in  place  the  free  ends  of  spring  wires  are  sprung  be- 
neath the  half  round  tubes  on  the  deciduous  molar  crown  and  exert  an 
occlusal  force  on  the  deciduous  molar  which  produces  a  development  of 
the  structures  in  that  region. 

Impactions  of  any  of  the  permanent  teeth  anterior  to  the  molars  can 
best  be  handled  by  the  use  of  finger  springs  soldered  to  the  lingual  wire. 
Fig.  619  shows  a  lingual  appliance  that  was  used  in  the  treatment  of 
two  impacted  canines.  The  tissues  were  removed  from  over  the  canines 
and  holes  were  drilled  into  the  tootli  to  receive  a  spur  that  was  attached 
into  the  canine.  In  fastening  a  spur  with  an  eyelet  into  the  canine  it 
has  been  suggested  that  the  hole  in  the  canine  be  threaded  and  the  spur 
also  threaded.  The  eyelet  is  then  screwed  into  the  threaded  hole  in  the 
canine  and  the  cement  only  acts  as  a  medium  of  protection.  The  end 
of  the  finger  spring  on  the  lingual  appliance  is  made  into  an  eyelet  for 
the  purpose  of  receiving  a  ligature  which  is  tied  into  the  eyelet  attached 


TREATMENT   OP    CASES 


439 


to  the  canine.  The  finger  springs  should  be  made  out  of  24-  or  22-gauge 
spring  gold.  The  appliance  shown  in  Fig.  619  was  used  to  treat  the  im- 
paction of  the  canines  until  the  teeth  were  nearly  in  proper  position 
in  the  dental  arch.  To  complete  the  movement  into  the  dental  arch  and 
correct  the  torsiversion  of  the  canines,  finger  springs  were  soldered  to 
the  buccal  surface  of  the  molar  bands,  and  the  lingual  wire  was  left  to 
reinforce  the  molar  anchorage.  The  appliance  is  shown  in  Fig.  620. 
In  some  cases  the  permanent  molars  become  impacted.  The  first  molar 
may  become  impacted  on  the  distal  surface  of  the  second  deciduous 
molar  or  the  second  or  third  molar  may  become  caught  on  the  tooth 
mesial.  An  excellent  appliance  for  use  in  such  impaction  is  the  ligature 
jack  as  used  by  Lourie  and  described  in  Figs.  221,  222,  and  223. 


Fig.   619. 


Fig.   620. 


Bilateral  Distoclusion  with  Labioversion,  or  Class  II,  Division  1 

Bilateral  distoclusion  with  labioversion,  or  Class  II,  Division  1, 
cases  are  those  that  are  characterized  by  the  distal  relation  of  the 
lower  arch,  the  width  of  one  premolar.  It  is  very  seldom  that  we  find 
the  mandibular  teeth  distal  to  a  greater  extent  (Fig.  621).  The  upper 
arch  is  narrow,  maxillary  anterior  teeth  protruding,  underdeveloped 
chin,  underdeveloped  mandible,  short  upper  lip,  thickened  lower  lip 
(Figs.  622  and  623),  abnormal  muscular  pressure,  further  complicated 
by  abnormal  breathing.  In  fact,  long-continued  mouth-breathing  may 
be  said  to  be  responsible  for  all  of  the  conditions  found  in  Class  II, 
Division  1.  Mouth-breathing  is  usually  caused  by  adenoids,  for  a  full 
description  of  which  see  Chapter  IV. 

The  first  requirement  in  the  treatment  of  these  cases  is  to  make 
certain  that  all  nasal  obstructions  have  been  removed.     It  should  be 


440  PRACTICAL   ORTHODONTIA 

recalled  that  the  nasal  cavity  in  these  patients  is  always  undersized, 
which  has  been  caused  by  the  lack  of  proper  development,  as  a  result 
of  mouth-breathing,  and  lack  of  atmospheric  pressure  brought  about 
by  disuse.  The  lack  of  development  of  the  nasal  cavity  can  be  rem- 
edied only  by  widening  the  dental  arch,  which  produces  a  transfor- 
mation in  the  bones  forming  the  nasal  cavity.  It  is  often  found  that 
the  nasal  septum  is  deflected  in  a  large  percentage  of  these  cases, 
which  is  due  in  part  to  the  improper  development  of  the  bones  that 
make  up  the  nasal  cavity.     While  it  is  a  fact  that  these  patients  gen- 


Fig.   621. — Extreme  distal    (posterior)    relation   of  lower  arch. 

erally  seek  relief  for  the  malocclusion,  still  they  will  always  be  greatly 
benefited  by  the  change  that  will  occur  in  the  nasal  cavity  as  a  result 
of  the  proper  treatment  of  the  malocclusion. 

Owing  to  the  extreme  facial  deformity  present  in  distoclusion  with 
protruding  superior  anterior  teeth,  or  Class  II,  Division  1  cases,  the 
literature  on  orthodontia  is  full  of  these  cases  and  of  the  different 
plans  of  treatment.  In  fact,  the  advancement  of  orthodontia  may  be 
traced  through  the  advancement  of  the  technique  in  the  treatment  of 
distoclusion  cases,  or  Class  II,  Division  1,  cases.  Therefore,  it  will  be 
appropriate  to  state  briefly  the  different  plans  of  treatment  as  prac- 
ticed in  the  past  and  at  the  present  time. 

One  of  the  first  plans  that  we  have  any  record  of  is  one  in  which 
the  case  was  treated  by  the  extraction  of  some  teeth.     An  upper  pre- 


TREATMENT    OF    CASES 


441 


molar  on  each  side  was  extracted;  first,  to  establish  harmony  in  the 
size  of  the  arches,  and  second,  to  reduce  the  protrusion  of  the  upper 


Fig.   622.  Fig.   623. 

Figs.   622   and   623. — Class  II,    Division    1    case,   caused   by   mouth-breathing. 


Fig.    624. — Typical   case   of   Class   II,    Division    1. 


anterior  teeth.     This  plan  of  treatment  made  the  upper  arch  conform 
to  the  underdeveloped  lower  arch,  improved  the  occlusion  slightly  and 


442  PRACTICAL   ORTHODONTIA 

changed  the  facial  profile.  Normal  occlusion  and  normal  facial  outlines 
were  not  recognized  by  this  plan. 

Owing  to  the  unsatisfactory  facial  results  and  the  lack  of  normal 
occlusion,  the  next  method  of  treatment  to  attract  attention  was  the 
one  introduced  by  Kingsley  and  known  as  "'.Jumping  the  bite."  This 
plan  has  for  its  object:  First,  the  establishment  of  the  normal  rela- 
tion of  the  arches  by  reducing  the  protrusion  of  the  superior  anterior 
teeth;  second,  the  forward  movement  of  the  mandible,  which  improves 
the  facial  outlines;  and  third,  the  establishing  of  normal  occlusion  of 
the  teeth. 

It  will  be  seen  that  the  results  that  were  hoped  for  in  this  plan  of 
treatment  were  much  more  attractive  than  those  that  were  obtained 
by  the  other  method  of  procedure.  The  treatment,  in  brief,  was  to 
expand  both  the  upper  and  the  lower  arches  and  reduce  the  protru- 
sion of  the  mandibular  anterior  teeth  until  both  arches  were  of  the  same 
size  and  shape.  Then  the  mandible  was  moved  forward  by  muscular 
action  until  the  teeth  were  in  their  proper  mesio-distal  relation.  The 
forward  movement  of  the  mandible  remedied  the  deformity  that  re- 
sulted from  the  underdeveloped  chin.  The  facial  outlines  and  the  oc- 
clusion of  the  teeth  were  much  improved  immediately  following  the 
completion  of  the  treatment.  However,  the  trouble  was  that  great 
difficulty  was  encountered  in  getting  the  mandible  to  stay  forward 
after  it  had  been  moved  by  muscular  action.  Various  forms  of  re- 
taining appliances  were  devised  and  the  hope  for  permanent  results 
was  based  on  the  belief  that  the  temporo-mandibular  articulation 
would  change,  so  as  to  keep  the  mandible  in  its  new  position  and  also 
that  the  body  of  the  mandible  would  change.  Owing  to  the  great 
tendency  of  the  ligaments  to  pull  the  mandible  back  to  its  former 
position,  the  author  has  grave  doubts  as  to  the  number  of  cases  treated 
by  this  plan  that  could  be  said  to  be  entirely  successful.  The  two 
plans  above  mentioned  were  not  wholly  satisfactory  and  therefore  ortho- 
dontists were  constantly  seeking  something  that  would  promise  better 
results. 

AVith  the  use  of  intermaxillary  anchorage,  as  described  by  Baker 
and  used  on  a  distoclusion,  or  Class  II,  Division  1  case,  a  new  plan  of 
treatment  was  given  to  orthodontia.  AVith  the  use  of  intermaxillary 
anchorage,  it  became  possible  to  move  the  maxillary  teeth  backward  and 
the  mandibular  teeth  forward.  The  forward  movement  of  the  lower 
teeth  was  the  great  feature  of  intermaxillary  anchorage.  Up  to  that 
time  there  was  no  means  of  bringing  about  this  condition,  for  the  plan 
known  as  "Jumping  the  bite"  moved  the  teeth  only  as  the  mandible 


TREATMENT   OF    CASES  443 

was  moved  by  muscular  action.  After  Baker  described  the  treatment  of 
his  case,  Angle  began  the  use  of  intermaxillary  anchorage  in  distoclu- 
sion  and  mesioclusion  cases.      The   following   was  accomplished: 

1.  Establishment  of  the  normal  mesio-distal  relation  of  the  inclined 
planes  of  the  teeth. 

2.  Widening  of  the  upper  arch  and  reducing  the  protrusion  of  the 
maxillary  anterior  teeth. 

3.  Movement  of  the  maxillary  teeth  backward  and  the  mandibular 
teeth  forward,  bringing  about  the  normal  relation  as  described  in  para- 
graph one. 

4.  Improvement  of  the  facial  outlines  of  the  individual  by  so  doing. 

5.  Production  of  normal  muscular  action  by  making  it  possible  for 
the  individual  to  close  the  lips  over  the  teeth. 

6.  Making  normal  breathing  possible  because  the  patient  could  close 
the  lips. 

More  satisfactory  results  could  be  obtained  with  this  plan  of  treat- 
ment than  from  any  of  the  others  mentioned.  The  great  improvement 
was  the  result  of  having  moved  the  lower  teeth  forward.  However, 
normal  occlusion  was  not  always  established  by  obtaining  the  proper 
relation  of  the  inclined  planes ;  for  in  moving  the  maxillary  teeth  back- 
ward and  the  mandibular  teeth  forward,  a  tipping  of  the  teeth  was  pro- 
duced, which  was  not  desired.  After  the  treatment  of  these  cases  it  of- 
ten occurred  that  the  chin  and  mandible  would  be  undersized.  For  this 
reason  it  was  believed  that  better  results  would  be  obtained  if  the  plan 
of  treatment  was  changed  slightly,  which  resulted  in  the  following 
plan,  the  object  of  which  was  to  establish  normal  occlusion  of  the 
teeth:  First,  by  widening  the  upper  arch  and  retracting  the  protrud- 
ing upper  anterior  teeth;  second,  by  moving  the  lower  teeth  forward 
the  entire  distance  (do  not  move  the  upper  molars  backward)  ;  third, 
by  making  such  anchorage  and  attachments  as  would  prevent  the  lower 
teeth  from  tipping,  which  would  bring  them  forward  in  an  upright 
position.  As  a  result  of  this  plan,  the  best  facial  outlines  were  obtained, 
the  mandible  was  developed  to  its  normal  size,  the  muscular  action  be- 
came normal  and  the  chin  was  developed. 

It  has  been  shown  in  the  majority  of  these  Class  II,  Division  1  cases 
that  the  maxillary  molars  are  not  too  far  forward.  Such  being  the  case, 
a  plan  that  would  approach  the  ideal  result  must  be  one  that  will  not 
move  these  teeth  backward.  Therefore,  our  efforts  should  be  directed 
toward  moving  the  lower  teeth  forward  and  developing  the  mandible. 

By  examining  a  large  number  of  these  cases,  by  studying  the  facial 
outlines  and  the  anatomy  of  the  temporo-mandibular  articulation,  the 


444  PRACTICAL   ORTHODONTIA 

author  is  convinced  that  the  great  deformity  that  we  encounter  in 
these  cases  in  the  mandibular  region  is  the  result  of  the  underdevelop- 
ment of  the  mandible  and  is  not  the  result  of  the  distal  location  of 
the  condyle.  These  cases  are  micromandibular  development  and  not 
post  version  of  the  mandible.  Therefore  our  treatment  should  be  of 
such  a  nature  as  will  produce  a  development  of  the  mandible  that  can 
be  brought  about  by  the  last-named  plan. 

Distoclusion  with  protruding  upper  anterior  teeth,  or  Class  II, 
Division  1  cases  are  found  at  all  ages — even  in  children  who  possess 
only  deciduous  teeth.  It  is  the  opinion  of  some  that  the  condition  may 
be  congenital ;  but  in  most  instances  it  is  the  result  of  some  acquired 
pathologic  condition,  usually  mouth-breathing,  the  mouth-breathing  gen- 
erally being  the  result  of  adenoids.  Treatment  is  indicated  as  soon  as 
the  malocclusion  is  discovered,  for  only  complications  can  come  by  wait- 


Fig.   625. — Distoclusion  with   labioversion   of  anterior  maxillary  teeth.      Class   II,   Division   1   case. 

Patient  five  years  of  age. 

Fig.  625  show's  a  case  of  distoclusion,  or  Class  II,  Division  1,  at  five 
years  of  age.  This  case  gave  a  clear  history  of  adenoids,  the  patient 
having  been  operated  on  one  year  previously.  Plain  bands  were 
placed  on  the  second  deciduous  molars,  after  wire  had  been  placed  be- 
tween them  and  the  first  deciduous  molars  to  produce  separation.  An 
eighteen-gauge  arch  was  used,  as  very  little  force  was  required  to 
move  the  teeth.  The  upper  arch  was  so  adjusted  that  it  rested  against 
the  superior  anterior  teeth  and  assumed  a  position  away  from  the 
canines.  The  sheath-hooks  were  placed  on  the  upper  arch  opposite 
the  canines;  the  lugs  on  the  upper  arch  were  not  allowed  to  rest 
against  the  tubes  on  the  molar  bands  at  the  beginning  of  the  treat- 


TREATMENT   OP    CASES 


445 


merit ;  wire  ligatures  were  placed  on  the  superior  canines  so  as  to  pro- 
duce widening  in  the  canine  region.  The  position  of  the  arch,  liga- 
tures and  lugs  is  shown  in  Figs.  626,  627,  and  628. 


Fig.   626. 


Fig.  627. 

Figs.    626   and   627. — Front   and   side  view   of  appliance   used    on    Fig.    625. 


446 


PRACTICAL    ORTHODONTIA 


The  lower  arch  was  placed  on  the  mandibular  tooth  with  the  anterior 
portion  in  close  contact  with  the  anterior  teeth,  with  a  slight  space 
between  the  canines  and  the  arch,  as  there  is  a  demand  for  a  slight 
expansion  in  the  canine  region;  the  lugs  on  the  lower  arch  are  against 
the  tubes  on  the  molar  bands,  for  it  is  the  intention  to  bring  all  of  the 


Fig.   628. 


Fig.    629. 
Figs.    628   and   629. — Occlusal   view   of   appliance   used   on   case   shown   in    Fig.    625. 


mandibular  teeth  forward.  Owing  to  the  ease  with  which  the  mandibu- 
lar teeth  move,  the  force  of  the  intermaxillary  ligature,  which  will  de- 
press the  upper  anterior  teeth,  will  also  start  the  mandibular  teeth  to 
moving  forward.     As  the  canines  of  the  upper  teeth  are  expanded,  the 


TREATMENT   OF    CASES  447 

pull  of  the  intermaxillary  rubbers  will  depress  the  anterior  teeth  with- 
out destroying  the  approximal  contact  of  the  teeth.  After  the  maxil- 
lary anterior  teeth  have  been  moved  distally  to  their  proper  position, 
which  is  determined  by  the  shape  of  the  dental  arch,  the  lugs  on  the  ex- 
pansion arch  are  allowed  to  rest  against  the  molars  and  the  expansion 
arch  so  changed  in  shape  that  it  rests  passive  in  contact  with  all  of 
the  teeth.  All  of  the  teeth  are  then  ligated  to  the  expansion  arch, 
so  as  to  obtain  as  much  resistance  as  possible,  which  is  used  as  an- 
chorage in  moving  the  mandibular  teeth  forward.  The  continued  use  of 
the  rubber  ligatures  will  move  the  mandibular  teeth  forward  until  thev 


Fig.    630. — Finished    result    of    Fig.    625. 

occupy  the  position  shown  in  Fig.  630.  The  teeth  were  retained  by 
the  use  of  passive  intermaxillary  retention,  consisting  of  a  band  placed 
on  the  maxillary  second  deciduous  molar  with  an  inclined  plane  on  the 
distal  side  of  it,  which  engaged  the  distal  portion  of  the  mandibular  sec- 
ond deciduous  molar.  (Fig.  631.)  This  device  was  worn  until  the  first 
molars  began  to  erupt,  and  was  then  taken  off.  Bands  were  placed  on 
the  mandibular  canines  with  a  bar  soldered  to  the  lingual  side  to  main- 
tain the  expansion  in  that  region,  but  nothing  was  placed  on  the  maxil- 
lary anterior  teeth ;  for  if  the  mandibular  teeth  are  held  and  lip  pressure 
is  normal,  the  maxillary  teeth  will  remain  normal.  If  the  lip  pressure 
is  subnormal,  retaining  appliances  will  hold  the  teeth  mechanically 
only,  and  when  removed  the  teeth  will  return  to  their  former  position 


448 


PRACTICAL    ORTHODONTIA 


regardless  of  how  long  the  appliance  was  worn.  Therefore,  greater  at- 
tention should  be  paid  to  the  natural  forces  of  retention  than  has  for- 
merly been  done. 

Fig.  633  shows  a  typical  ease  of  distoclusion  with  protruding  upper 
anterior  teeth,  or  Class  IT,  Division  1,  at  the  age  of  seventeen  years. 
The  facial  outline  of  the  patient  is  shown  in  Figs.  634  and  635.     The 


Fig.   631. — Plain   band   on  maxillary   molar   with   cast   lug  to   hold   mandibular   molar   forward. 

(Suggested  by  Brady.) 

short  upper  lip,  receding  chin  and  underdeveloped  mandible  are  char- 
acteristic of  these  cases.  In  order  to  improve  the  facial  outline  of  the 
patient,  it  will  be  necessary  to  move  the  mandibular  teeth  forward, 
widen  the  upper  arch,  and  reduce  the  protrusion  of  the  maxillary  ante- 


Fig.   632. — Occlusal   view  of  finished  case. 


rior  teeth.    The  best  results  will  be  obtained  by  moving  the  lower  teeth 
forward  bodily,  which  will  cause  a  development  of  the  mandible. 

Wire  is  placed  around  the  approximal  contact  points  of  the  first 
molars  to  produce  a  slight  separation.  After  the  wire  has  remained 
in  place  twTenty-four  hours  or  more,  clamp-bands  are  placed  on  the 
first  molars,  care  being  taken  to  have  the  screws  lie  close  to  the  lin- 


TREATMENT    OF    CASES 


449 


Fig.    633. — Distoclusion    with    labioversion    of    anterior    maxillary    teeth. 
Patient   seventeen   years  of  age. 


Class    II,     Division     1. 


Fig.   634. 


Fig.   635. 


Figs.    634   and    635. — Effect   of  mouth-breathing   and   distal    relation    of   lower   arch.      Short   upper 

lip,   underdeveloped   mandible. 


450  PRACTICAL    ORTHODONTIA 

glial  surfaces  of  the  premolars.  If  the  tubes  on  the  bands  do  not  oc- 
cupy the  proper  position,  they  are  removed  and  soldered  so  that  the 
arch  will  occupy  the  proper  relation  to  the  teeth.     The  position  of  the 


Fig.  636. — Side  view,  showing  intermaxillary  anchorage. 


Fig.   637. — Front  view,   showing   intermaxillary   anchorage. 


TREATMENT    OF    CASES 


451 


upper  expansion  arch  is  shown  in  Fig.  636.  It  will  be  seen  that  the 
anterior  part  of  the  arch  rests  against  the  maxillary  anterior  teeth ;  that 
the  arch  stands  away  from  the  canines,  for  they  must  be  expanded; 
and  that  the  nuts  are  screwed  forward  in  order  not  to  touch  the  tubes 
on  the  molar  bands.     These  details  must  be  observed  carefully  in  or- 


Fig.   638. 


Fig.   639. 

Figs.   638  and   639. — Occlusal  view   of   appliances.     Upper   arch   rests   against   anterior   teeth,    nuts 
away  from  tubes.     Mandibular  anterior  teeth  ligated  to  arch  and  nuts  against  tubes. 


452 


PRACTICAL    ORTHODONTIA 


dcr  to  secure  the  greatest  benefit  from  the  regulating  appliance.  At 
the  beginning  of  the  case,  wire  ligatures  are  placed  on  the  maxillary 
canines  and  first  premolars  (Fig.  638),  which  makes  reciprocal  an- 
chorage between  the  two  sides.  Intermaxillary  anchorage  is  used  on 
this  case,  the  lower  arch  having  been  adjusted  as  follows:     The  lower 


Fig.   640. — Condition   of  teeth   at  the  time  active   intermaxillary  anchorage  was   employed. 


Fig.   641.  •  Fig.   6-12. 

Figs.   641   and  642. — Changed   facial   results. 


TREATMENT   OF    CASES  453 

expansion  arch  is  placed  on  the  lower  teeth  so  that  it  will  occupy  the 
position  shown  in  Fig.  637.  Slight  expansion  is  indicated  in  the  canine 
region,  but  the  anterior  part  of  the  arch  should  rest  against  the  lower 
anterior  teeth,  for  they  are  to  be  carried  forward  only  as  the  molars 
and  premolars  are  carried  toward  by  intermaxillary  anchorage  (Fig. 
639).  The  lower  incisors  may  be  prevented  from  tipping  by  soldering 
spurs  on  the  arch,  as  shown  in  Fig.  551  and  then  ligating  the  teeth  to 
the  arch.  The  spur  causes  the  tooth  to  maintain  a  perpendicular  posi- 
tion. Should  it  be  necessary  to  move  the  apex  of  the  tooth  faster  than 
the  crown,  this  can  be  accomplished  by  placing  a  rubber  between  the 
tip  of  the  spur  and  the  tooth. 


Fig.  643. — Retention  of  case  shown  in   Fig.   633. 

After  the  upper  teeth  have  been  expanded  and  the  anterior  teeth 
brought  to  the  proper  position  with  each  other,  the  nuts  on  tiie  upper 
arch  are  allowed  to  touch  the  tubes  on  the  upper  molar  bands  so  that 
the  resistance  of  all  of  the  upper  teeth  will  be  pitted  against  all  of 
the  lower  teeth. 

It  is  an  anatomic  fact  that  more  force  is  necessary  to  move  the 
upper  teeth  backward  than  is  required  to  move  the  lower  teeth  for- 
ward, and  this  knowledge  aids  us  materially  in  the  treatment  of  this 
class  of  cases.  The  continued  use  of  intermaxillary  anchorage  will 
bring  the  lower  teeth  forward  to  their  proper  position,  but  they  must 
not  be  moved  rapidly. 

In  the  majority  of  distoclusion,  or  Class  II,  Division  1  cases,  a  con- 


454 


PRACTICAL    ORTHODONTIA 


dition  exists  that  may  be  described  as  infraversion  of  the  lower  molars. 
Some  have  called  it  supraversion  of  the  incisors,  but  after  an  examina- 
tion of  many  patients  and  skulls,  the  author  is  convinced  that  the  diffi- 
culty lies  in  the  molar  region ;  therefore,  the  best  results  will  be  ob- 
tained by  some  plan  of  treatment  that  will  produce  an  elongation  of  the 
mandibular  molars,  and  that  is  what  results  when  the  mandibular  an- 
terior teeth  are  ligated  stationary  to  the  arch.    The  position  of  the  man- 


Upper  isT.  molar 


clamp 
band 


Plain 
Dand 


"Spur  tor  ruober 
on  Lower  1st.  molar 


Fig.    644. — Active   intermaxillary    retention    used    in   case    shown    in    Fig.    633. 


Fig.   645. — Side  view  of  retention  used  in  case  shown  in   Fig.   633. 

dibular  molar  roots  is  such  that  the  continuous  pull  of  the  rubbers  tends 
to  elongate  these  teeth  as  they  are  being  brought  forward.  If  attempts 
are  made  to  move  them  too  fast,  there  will  be  too  much  elongation  of 
the  mandibular  molars ;  therefore,  it  becomes  important  that  we  watch 
these  cases  carefully  so  as  to  keep  the  forces  employed  evenly  balanced. 
Fig.  645  shows  the  case  after  the  teeth  had  been  moved  to  their 
proper  position.     The  change  in  the  mandible  can  be  seen  by  compar- 


TREATMENT    OF    CASES 


455 


ing  Figs.  634  and  635  with  Figs.  641  and  642,  the  latter  having  heen 
made  after  treatment.  The  movement  of  the  lower  teeth  forward  has 
caused  a  lengthening  of  the  mandible. 

The  retention  of  the  case  consisted  in  placing  bands  on  the  upper 
canine  and  soldering  a  wire  on  the  labial  surface  of  the  bands  so  as 
to  rest  against  the  labial  portion  of  the  teeth  (Fig.  643).  The  wire  is 
placed  on  the  labial  side  in  order  to  secure  greater  efficiency.     A  small 


Fig.   646. 


Fig.  647. 
Figs.    646   and   647. — Occlusion   plan   of   retainer   used   on   case   shown   in   Fig.    633, 


456 


PRACTICAL    ORTHODONTIA 


spur  is  soldered  on  the  disto-labial  portion  of  the  canine  band  (Figs. 
644  and  64.5)  to  engage  the  intermaxillary  rubber  that  will  be  used  in 
retention.  In  order  that  this  retaining  appliance  may  be  of  any  value, 
the  wire  extending  from  one  canine  to  the  other  must  be  made  of  some 
material  rigid  enough  to  hold  the  canines  labially,  for  if  they  "col- 
lapse" all  of  the  upper  teeth  will  move  to  positions  of  malocclusion. 
The  retainer  is  shown  in  Fig.  646. 


Fig.  648. — Model  showing  triangular  spur  and  tube  used  with  lingual  wire.      (Fernald.) 


Fig.    649. — Square   labial    wire    used   to  hold   anterior    teeth   and   prevent    rotation    of   canines. 

(Fernald.) 

The  lower  teeth  are  retained  by  making  plain  bands  for  the  first 
molars  and  canines.  A  wire  is  shaped  to  tit  the  lingual  side  of  the 
teeth  and  is  soldered  to  the  lingual  side  of  the  bands  that  retain  the 
teeth,  as  shown  in  Fig.  647. 

A  spur  is  soldered  on  the  mesio-occlusal  angle  of  the  molar  bands 
to  engage  the  intermaxillary  ligature  that  is  used  for  retention    (Fig. 


TREATMENT   OF    CASES  457 

645).  The  mesio-distal  relation  of  the  teeth  is  retained  by  wearing  the 
intermaxillary  rubbers.  These  rubbers  must  be  strong  enough  to  resist 
the  backward  tendency  of  the  teeth.  This  form  is  called  active  intermax- 
illary retention.  It  holds  the  lower  teeth  forward,  and  the  constant 
pull  of  the  rubber  ligatures  holds  the  lower  molars  in  their  proper  posi- 
tion and  relation,  as  they  have  been  moved  from  infraocclusion. 

One  of  the  difficulties  with  the  form  of  retaining  appliances,  as 
shown  in  Figs.  646  and  647,  is  that  the  appliance  is  too  rigid  and  fixed 
and  does  not  permit  the  removal  of  the  parts  for  the  brushing  of  the 
teeth.  To  obviate  this  difficulty,  Fernald  has  designed  a  lock  for  use 
with  the  lingual  retaining  wire,  which  makes  it  possible  to  remove  the 


Fig.   650. — Position   of  lingual  wire   locked   in   molar  tubes.      (Fernald.) 

lingual  wire.  The  lock  consists  of  a  triangular  tube  and  a  triangular 
spur  that  fits  into  the  triangular  tube.  The  tube  is  soldered  to  the 
band  and  the  spur  is  soldered  to  the  lingual  wire.  An  enlarged  model 
of  the  device  is  shown  in  Fig.  648.  Plain  bands  are  made  for  the 
molars  to  which  the  triangular  split  tube  is  soldered.  Plain  bands 
are  made  for  the  canines,  which  have  a  notch  made  on  the  lingual 
side  into  which  the  lingual  arch  rests.  On  the  labial  side  of  the 
canine  bands  is  soldered  a  square  tube  perpendicular  with  the  long 
axis  of  the  tooth  that  is  to  receive  the  end  of  a  square  wire,  as  is  shown 
in  Fig.  649.  This  square  wire  resting  in  the  square  tube  prevents  the 
canines  from  rotating  as   a   result  of  the   pull   of  the  intermaxillary 


458 


PRACTICAL    ORTHODONTIA 


rubbers  used  in  retention,  and  by  changing  the  relation  of  the  end  of 
the  wire  as  it  enters  the  tube,  a  variety  of  movements  of  the  canines 


Fig.  651. 


Fig.   652. 
Figs.    651    and   652. — Removable   retaining   appliance    in    which    all    parts   are    separate.      (Beaser.) 


can  be  accomplished,  should  it  be  so  desired.     A  spur  is  soldered  on 
the  disto-labial  angle  of  the  canine  band  for  the  attachment  of  the  in- 


TREATMENT   OF    CASES 


459 


termaxillary  rubber.  Fig.  650  shows  the  position  of  the  lingual  wire 
with  the  locks  on  the  lingual  sides  of  the  molar  bands  and  the  lingual 
wire  resting  in  the  seat  on  the  canine  band.  A  removable  retaining 
appliance  for  use  in  distoclusion  cases  has  been  designed  by  Beaser. 
The  various  parts  of  the  appliance  are  shown  in  Figs.  651  and  652. 


Fig.   653. 


Fig.   6S4. 
Figs.    653   and   654. — Removable   retaining  wire   in   position   on   models.      (Deaser.) 


The  appliance  may  be  made  from  any  kind  of  material  and  consists 
of  plain  bands  for  the  molars  and  canines.  A  16-gauge  vertical  tube 
is  soldered  on  the  lingual  surface  of  the  molar  bands  and  a  slot  cut 
into  the  tube  from  the  occlusal  end,  large  enough  to  permit  a  20- 
gauge  wire  to  slip  into  it  easily.     The  lingual  wire  is  fitted  to  the 


460 


PRACTICAL    ORTHODONTIA 


lingual  surface  of  the  teeth  on  the  model,  and  the  end  of  the  wire  is 
cut  off  flush  with  the  inner  surface  of  the  vertical  tube.  To  the  end 
of  the  lingual  wife  is  soldered  a  piece  of  16-gauge  wire,  which  is  cut 


Fig.    655. 


Fig.   656. 
Figs.   655   and   656. — Intermaxillary    rubbers   used   with    removable    retaining   appliance.      (Beaser.) 

off  the  same  length  as  the  vertical  tube,  and  makes  a  "T"  on  the 
end  of  the  lingual  wire.  This  piece  of  16-gauge  wire  fits  in  the  vertical 
tube  with  the   20-gauge  lingual  wire  lying  in  the  slot  and  prevents 


TREATMENT   OF    CASES 


461 


the  molars  from  rotating.  Small  hooks  are  soldered  to  the  linguo- 
cervical  border  of  the  canine  bands  to  engage  the  lingual  wire  and  to 
hold  it  in  place  (Figs.  653  and  654).  To  prevent  the  outward  ten- 
dency of  the  anterior  teeth,  a  piece  of  18-gauge  tubing  is  soldered  on 
the  labial  surface  of  the  canine  bands  and  a  slot  is  cut  into  the  tube 
mesially  and  distally  from  the  cervical  end  about  two-thirds  of  its 
length,  large  enough  to  permit  the  passage  of  a  20-gauge  wire.     This 


Fig.   657. 


Fig.   658. 
Figs.    657   and   65S. — Side   and    front   views   of  distocluslon   case.      (Lourie.) 


can  best  be  accomplished  by  cutting  the  tube  about  half  through  for 
the  desired  length  and  then  soldering  to  the  band.  A  piece  of  20- 
gauge  wire  is  then  cut  the  desired  length,  which  is  long  enough  to 
make  a  hook  on  each  end  after  it  is  adjusted  to  the  incisors  and 
slipped  in  place  in  the  notch  in  the  tube  on  the  canine  band.  To  pre- 
vent rotation  of  the  canine,  an  18-gauge  spur  is  soldered  on  the  20-gauge 


462 


PRACTICAL    ORTHODONTIA 


labia]  wire  to  pass  into  the  18-gauge  tube  on  the  canine  band.  Intermax- 
illary rubbers  arc  adjusted  from  hooks  that  have  been  soldered  on  the 
lower  molar  bands  to  the  bent  end  of  the  20-gauge  wire  in  the  incisors 
(Figs.  655  and  656). 

Distoclusion,  or  ('lass   II,   Division    1    eases  can  also  be  successfully 
treated  by  means  of  the  lingual  arch  used  in  combination  with  the  labial 


Fig.    659. — Occlusal,  view    of    case    shown    in 
Figs.    657    and    658.      (Lourie.) 


Fig.   660. — Occlusal  view  of  Fig.   659    with  lin- 
gual  arch   in   place.      (L,ourie.) 


Fig.    661. — Labial   wire  with   spur  extensions 
which       make       an       inconspicuous      appliance. 
(IyOurie.) 


Fig.   662. — Study  model   of  case  shown  in   Fig. 
657    made    during   treatment.      (Lourie.) 


arch  and  spur  extensions,  thereby  making  an  appliance  that  is  not  so 
conspicuous  as  when  the  regular  labial  arch  is  used.  Figs.  657  and  658 
show  a  case  of  distoclusion  with  protruding  upper  anterior  teeth.  Fig. 
659  shows  the  occlusal  view  of  the  upper  model,  which  shows  the  ex- 
pansion necessary  in  the  canine  and  premolar  region.  Plain  bands  were 
adjusted  to  the  upper  molars,  which  carry  buccal  tubes  as  shown  in 
Fig.  660.     Fig.  660  is  a  study  model  that  was  made  during  treatment 


Treatment  of  cases 


463 


and  shows  the  application  of  the  lingual  arch.  The  lingual  arch  was 
soldered  to  the  lingual  side  of  the  molar  bands,  and  by  lunching  the  lin- 
gual wire  with  the  wire-stretchers  the  dental  arch  was  widened.    The  lin- 


Fig.    663. — Photograph    of   patient    wearing   labial    arch   with    spur   extensions.      (Lourie.) 


Fig.   664. — Class  II,   Division    1,   Subdivision   case  unilateral  distoclusion   with   protruding 
maxillary  anterior  teeth. 


gual  arch  was  made  of  19-gauge  iridio-platinum  and  rested  against  the 
premolars  and  canines  but  did  not  touch  the  incisors,  as  they  were  moved 


464 


PRACTICAL    ORTHODONTIA 


Fig.    665. 


Fig.    666. 


Figs.    665    and    666.— Facial    outlines    of    Class   II,    Division    1,    Subdivision. 


4 

P 

-Mr , 
— <* 

• 

"jpK 

k-.T-" 

wiiiii 

.  .1 

•  • 

•J 

ijff'  4pr 

J 

-.'  i^i-^OTteiis. 

Fig.   667.  Fig.   668. 

Figs.   667   rmd  668.— Showing  facial  outlines  after   development  of  mandible. 


TREATMENT    OF    CASES  465 

with  the  spurs  on  the  labial  arch.  Fig.  661  shows  the  lahial  arch  with 
the  spur  extension,  which  rests  against  the  incisors  and  carries  them 
distally  as  the  lingual  arch  widens  the  canine  and  premolar  region. 
This  appliance  does  not  require  any  ligatures  on  the  maxillary  teeth  and 
the  only  part  that  is  visible  is  the  small  extension  spurs  on  the  labial 
arch.  Intermaxillary  anchorage  is  used  in  the  usual  manner  to  shift  the 
mesio-distal  relation  of  the  arches.  Fig.  662  is  a  study  model  made  to 
show  the  mesio-distal  relation  of  the  arches,  and  shows  clearly  the 
progress  of  treatment.  Fig.  663  shows  the  small  amount  of  the  appliance 
that  is  visible  in  the  patient  's  mouth. 

Unilateral  Distoclusion  with  Protruding  Anterior  Teeth,  or 
Class  II,  Division  1,  Subdivision 

Unilateral  Distoclusion,  or  Division  1.  Subdivision,  includes  such 
cases  as  are  distal  on  one  side  ami  normal  mesio-distally  on  the  other 
(Fig.  664).  They  present  the  same  other  symptoms  as  are  found  in 
the  division.  Unilateral  cases  are  treated  in  very  much  the  same  man- 
ner as  the  bilateral.  It  is  necessary  to  widen  the  upper  dental  arch  and 
to  reduce  the  protrusion  of  the  upper  anterior  teeth.  This  is  done  by 
adjusting  the  upper  expansion  arch  in  the  same  manner  as  is  done  in 
the  division  just  described.  The  lower  expansion  arch  is  also  adjusted 
as  was  done  in  the  division.  Intermaxillary  rubbers  are  placed  on  the 
appliance  to  reduce  the  protrusion  of  the  maxillary  teeth  and  the  maxil- 
lary canines  are  widened  as  they  were  in  the  case  above  mentioned.  Af- 
ter the  maxillary  anterior  teeth  have  been  moved  backward  to  the 
proper  place,  a  light  rubber  is  worn  on  the  normal  mesio-distal  side, 
while  on  the  abnormal  side  a  strong  rubber  is  employed  to  bring  the 
lower  forward  on  that  side. 

It  will  be  noted  by  studying  the  profile  of  the  patient  that  the  facial 
deformity  is  nearly  the  same  as  it  is  in  the  division.  In  fact,  in  the 
subdivision  we  find  just  as  great  a  facial  deformity  and  the  mandible 
just  as  deficient  (Figs.  667  and  668)  on  the  average  as  we  do  in  the 
division,  which  proves  that  the  lack  of  development  of  the  mandible 
is  due  entirely  to  the  abnormal  muscular  pressure. 

After  the  teeth  have  been  moved  into  the  proper  position,  they  are 
retained  in  the  same  manner  as  described  in  the  division.  It  will  be 
necessary  to  wear  a  retaining  rubber  ligature  on  the  normal  side  for  a 
while  to  hold  back  the  retracted  superior  anterior  teeth,  until  the 
pressure  of  the  lip  becomes  normal. 


466  PRACTICAL    ORTHODONTIA 

Bilateral  Distoclusion  with  Retruding  Anterior  Teeth,  or 
Class  II,  Division  2 

In  the  treatment  of  Class  II,  Division  2,  we  have  a  class  of  eases  that 
are  found  in  older  patients  than  in  Division  1.  At  least,  the  author  has 
never  seen  a  Class  II,  Division  2  case  in  as  young  a  patient  as  is  found 


Fig.   669. 


Fig.   670. 

Figs.    669    and   670. — Class   II,    Division   2   case.      Side   views.      Bilateral    distoclusion   with    linguo- 
version   of  anterior   maxillary   teeth. 


TREATMENT    OF    CASES 


467 


in  Class  II,  Division  1.  The  majority  of  cases  and  patients  seen  by  the 
author  during  his  practice,  gave  a  history  of  having  been  mouth-breath- 
ers at  one  time,  but  probably  there  are  other  factors  that  also  cause  this 
condition  of  malocclusion.  By  far  the  greater  number  have  had  opera- 
tions for  adenoids  or  have  been  troubled  with  nasal  obstruction  at  some 
time.  The  author  is  of  the  opinion  that  these  patients  were  at  some  time 
mouth-breathers  and  that  the  abnormal  muscular  and  atmospheric 
pressure  has  permitted  the  mandibular  molars  and  teeth  to  assume  a 
position  distal  to  normal.     The  teeth  have  protruded,  the  tongue  has 


Fig.    671. — Bilateral    distoclusion    with    linguoversion    of    anterior    maxillary    teeth,    or    Class    II, 

Division   2.      Front   view. 


been  in  the  lower  part  of  the  mouth,  and  the  lips  have  acted  abnormally ; 
then,  as  a  result  of  an  operation  or  change  in  environment,  normal 
breathing  has  become  possible  and  the  patient,  conscious  of  the  de- 
formity, has  closed  the  lips,  with  the  result  that  the  upper  and  lower 
lips  have  forced  the  maxillary  anterior  teeth  back  against  the  mandibular 
anterior  teeth.  With  the  tongue  held  in  the  upper  part  of  the  mouth,  the 
upper  arch  has  developed  to  nearly  the  proper  width,  which  develop- 
ment was  also  stimulated  by  nasal  breathing.  As  a  result  of  these  fac- 
tors, Class  II,  Division  2,  differs  from  Class  II,  Division  1,  in  every  re- 
spect except  in  the  distal  relation  of  the  lower  dental  arch.  The  up- 
per teeth  are  bunched  and  retrucling,  the  upper  arch  nearly  the  nor- 
mal width,  the  mandible  nearly  normal  in  development,  and  the  chin 


468  PRACTICAL   ORTHODONTIA 

normal  or  well  developed.     These  last  conditions  have  all  been  the  re- 
sult of  normal  muscular  and  normal  atmospheric  pressure. 

Remembering,  then,  the  conditions  that  are  present,  the  most  suc- 
eessful  plan  of  treatment  would  he  one  that  would  expand  the  upper 
arch  in  the  canine  and  incisor  region,  expand  the  lower  dental  arch, 
and  bring  the  lower  teeth  forward  to  their  proper  position.  It  will 
not  be  necessary  to  attempt  to  secure  a  development  of  the  mandible 
(unless  it  is  demanded)  for  in  the  majority  of  cases  the  chin  and  man- 
dible are  well  developed.  Therefore,  there  is  less  to  do,  and  if  properly 
handled,  Division  2  is  easier  to  treat  than  Division  1.  However,  the 
author  has  observed  that  more  difficulty  arises  in  the  treatment  of  Divi- 
sion 2  cases  than  in  those  of  Division  1.  The  reader  should  be  cau- 
tioned against  thinking  that  these  cases  can  lie  treated  in  a  "slip-shod" 
manner. 

Owing  to  the  fact  that  the  upper  anterior  teeth  must  be  moved  labially 
(Figs.  669,  670,  and  671),  it  will  be  necessary  to  adjust  the  expansion 
arch  in  the  same  manner  as  if  a  case  of  Class  I,  or  neutroclusion  were 
to  be  treated.  The  expansion  arch  is  away  from  the  superior  anterior 
teeth,  as  shown  in  Fig.  672.  Wire  ligatures  are  placed  on  the  anterior 
teeth  and  the}*  are  moved  into  the  proper  relation  with  each  other.  The 
lower  expansion  arch,  or  alignment  wire,  is  placed  on  the  teeth,  the 
dental  arch  is  expanded  and  the  teeth  moved  into  their  proper  position. 
After  the  teeth  in  the  upper  arch  have  been  moved  into  the  position  that 
they  should  occupy,  after  the  upper  arch  has  been  expanded  and  the  an- 
terior teeth  have  moved  labially,  then,  and  not  until  then,  should  inter- 
maxillary anchorage  be  used.  If  intermaxillary  anchorage  is  used  at  the 
time  the  maxillary  anterior  teeth  are  being  moved,  too  much  stress  will 
be  exerted  on  the  upper  molars  and  they  will  be  pushed  distally.  After 
the  anterior  teeth  have  been  moved,  the  expansion  arch  should  be  ad- 
justed in  such  a  manner  as  to  rest  against  all  of  the  teeth,  and  then  all 
of  the  upper  teeth  should  be  wired  to  the  alignment  wire.  This  gives 
the  resistance  of  the  entire  upper  dental  arch  as  anchorage  to  move  the 
lower  teeth  forward.  It  may  be  necessary  in  some  cases  to  place  spurs 
on  the  lower  expansion  arch  to  prevent  the  tipping  of  the  lower  incisors. 
The  mandibular  teeth,  having  been  moved  forward  into  their  proper 
position,  are  retained  by  both  reciprocal  and  intermaxillary  retention. 

The  maxillary  teeth  are  retained  by  placing  bands  on  the  first  molars 
and  canines.  A  lingual  wire  is  soldered  on  the  molar  and  canine  bands, 
as  shown  in  Figs.  678  and  679.  A  spur  is  soldered  on  the  disto-labial 
angle  of  the  canine  band  to  hold  the  rubber  that  will  be  used  as  inter- 
maxillary retention.    It  will  be  observed  in  the  upper  retainer  that  the 


TREATMENT    OF    CASES 


469 


Fie-,    (u. 


Fig.   673. 

Figs.    672    and    673  — Position    of    upper    and    lower    appliances    at    the    beginning    of    treatment. 


470 


PRACTICAL   ORTHODONTIA 


Fig.  674. 


Fig.   675. 

Figs.    674    and    675. — Views    of    the    appliances   as    upper   and    lower    dental   arches    are    being 
expanded   before   intermaxillary   anchorage   is   used. 


TREATMENT   OF    CASES 


471 


Fig.   676. 


Fig.   677. 

Figs.    676    and    677. — Showing    use    of    intermaxillary    anchorage    after    dental    arches    have    been 
expanded    to   move   mandibular   teeth    mesially    (forward). 


472 


PRACTICAL    ORTHODONTIA 


Fig.   678. 


Fig.    679. 
Figs.   678  and  679. — Showing  plan  of  retention   for  bilateral   distoclusion,   or   Class   II,   Division  2. 


TREATMENT    OF    CASES 


473 


wire  is  on  the  lingual  side  of  the  teeth  in  Division  2,  while  in  Division  1 
the  appliance  is  placed  on  the  labial  side. 

The  lower  teeth  are  retained  by  plain  bands  from  the  molars  and 
canines  and  a  wire  is  placed  on  the  lingual  side,  as  shown  in  Fig.  679. 
A  spur  is  soldered  on  the  mesio-lmccal-occlusal  angle  of  the  lower 
molar  band  to  engage  the  lower  end  of  the  rubber  that  is  attached  to 
the  spur  on  the  upper  canine  band.  The  pressure  of  the  rubbers  is 
diminished  gradually  by  having  the  patient  wear  lighter  rubbers  dur- 
ing the  period  of  retention.  Figs.  681,  682,  and  683  show  the  result 
of  the  treatment. 


Fig.    680. — Showing  active   intermaxillary   retenti 

Division 


n    in   bilateral    distoclusion,    or   Class   II, 


Since  the  treatment  is  the  same  in  all  cases,  the  author  feels  that  it 
is  unnecessary  to  take  up  other  cases  here. 

Bilateral  distoclusion  cases  with  bunched  anterior  teeth,  or  Class 
II,  Division  1,  in  3Toung  patients  and  in  some  types  of  older  patients 
can  be  advantageously  treated  with  the  lingual  arch,  as  suggested  by 
Lourie  and  Mershon.  The  case  here  shown  is  taken  from  Lourie's 
practice.  Fig.  684  shows  the  side  view  of  the  models  of  a  patient 
six  years  of  age.  There  is  a  distal  relation  of  the  lower  arch  to  the 
upper.     Fig.  685  shows  the  occlusal  view  of  the  case,  and  it  can  be 


474 


PRACTICAL    ORTHODONTIA 


Fig.    681. 


Fig.   682. 
Figs.   681   and  682. — Result  of  treatment  of  case  shown   in   Figs.    669   and   670. 


TREATMENT   OF    CASES 


475 


Fig.  683. — Front  view  of  case  shown  in   Fig.   676  after  treatment. 


Fig.    684. — Bilateral   distoclusion.      (Lourie.) 


Fig.  685. — Occlusal  view  of  bilateral  distoclusion  case.      (Eourie.) 


476 


PRACTICAL    ORTHODONTIA 


seen  that  both  the  upper  and  the  lower  teeth  require  expansion  in 
addition  to  the  shifting  of  the  occlusal  relation,  as  shown  in  Fig.  684. 
Bands  were  fitted  to  the  second  mandibular  deciduous  molars  and  a 
lingual  alignment  wire  of  19-gauge  iridio-platinum  was  soldered  to  the 
bands,  as  is  shown  in  Fig.  686.  Plain  bands  were  placed  on  the  upper 
first  molars  and  an  alignment  wire  of  19-gauge  iridio-platinum  was  ad- 
justed, as  shown  in  Fig.  686.  In  order  to  better  control  the  expansion 
of  the  deciduous  canines  above,  spurs  were  soldered  to  the  lingual 


Fig.    686. — Lingual   wires   adjusted    to   case   shown    in    Fig.    685.      (Lourie.) 


Fig.   687. — Study   model    of    Fig.    685.      Made   during  treatment.      (Lourie.) 


arch,  as  can  be  seen  in  the  illustration.  These  extension  spurs  could 
be  bent  and  thereby  better  control  the  movement  of  the  deciduous 
canines.  On  the  buccal  surface  of  the  maxillary  molar  band  there  is 
attached  an  extension  for  the  attachment  of  the  intermaxillary  rubber; 
the  other  end  of  the  rubber  is  attached  to  a  spur  on  the  buccal  surface 
of  the  mandibular  molar  bands.  The  buccal  extension  for  the  use  of 
the  intermaxillary  anchorage  is  shown  in  Fig.  687,  which  also  shows 


TREATMENT   OF    CASES 


477 


Fig.   688. 


Fig.   689. 

Figs.    688   and   689. — Mesioclusion,    or   Class    III,    case.      A    type    often    treated   by   extraction   in 

former  days. 


478  PRACTICAL    ORTHODONTIA 

the  changed  occlusal  relations.  This  appliance  is  entirely  inconspic- 
uous, as  no  bands  or  ligatures  were  used  on  the  anterior  teeth  and  as 
there  was  nothing  that  could  be  seen.  The  very  nature  of  the  tooth 
movement  required  in  distoclusion  cases  with  retruding  anterior  teeth, 
makes  this  appliance  very  desirable.  Owing  to  the  inconspicuousness 
of  the  lingual  wire,  both  patients  and  parents  are  always  greatly 
pleased  with  it. 

Unilateral  Distoclusion  with  Retruding  Teeth,  or  Class  II, 
Division  2,  Subdivision 

The  treatment  of  the  subdivision  of  Class  II,  Division  2,  is  the 
same  as  the  treatment  of  the  division ;  that  is,  the  case  is  started  in 
the  same  way,  but  the   intermaxillary  ligature  is  only  worn  on  the 


Fig.   690. — Showing  form  of  appliances  used  on  cases  similar  to  case  shown  in  Fig.  689.    (Angle.) 

side  that  has  an  abnormal  mesio-distal  relation  of  the  arches.       There 
is  never  any  necessity  of  wearing  the  rubber  on  the  normal  side. 

Bilateral  Mesioclusion,  or  Class  III 

Mesioclusion,  or  Class  III,  includes  those  cases  that  have  a  mesial 
relation  of  the  lower  dental  arch.  As  was  shown  under  the  classifica- 
tion of  malocclusion,  different  types  of  mesioclusion,  or  Class  III  ex- 
ist, which  fact  makes  possible  different  methods  of  treatment.  While 
we  should  try  to  get  normal  occlusion  and  normal  facial  outlines  in 
all  cases,  the  different  types  will  render  necessary  a  different  technique 
of  treatment.  Mesioclusion,  or  Class  III,  cases  are  more  rare  than 
any  other  class,  or  at  least  have  been  so  in  the  author's  practice. 
Therefore,  it  is  impossible  at  the  present  time  for  the  author  to  show 
finished  results  of  all  of  the  types,  but  the  plan  of  treatment  will  be 
outlined. 


TREATMENT   OF    CASES 


479 


Figs.  688  and  689  show  a  mesioclusion,  or  Class  III,  ease  in  which 
the  maxillary  teeth  are  in  rather  even  alignment ;  the  mandibular 
teeth  are  "bunched,"  and  it  will  be  noted  that  the  mandibular  first 
premolars  have  been  extracted.  When  the  teeth  are  in  occlusion  it  will 
be  seen  that  there  is  an  end-to-end  bite  of  the  anterior  teeth. 

This  case  recalls  one  of  the  common  plans  of  treatment  of  this  type 
of  mesioclusion,  or  Class  III,  cases  that  was  followed  a  few  years 
ago;  namely,  the  extraction  of  the  mandibular  first  premolars  and  the 
distal  movement  of  the  canines  and  incisors  until  they  were  lingual  to 
the  upper  teeth.     The  distal  movement  of  the  canines  and  anterior 


Fig.   691. — Mesioclusion,   or  Class  III,   case.      Patient   twelve  years  of  age. 


teeth  was  accomplished  by  the  use  of  the  traction  screw  and  stationary 
anchorage.  The  appliance  was  arranged  as  shown  in  Fig.  690.  This 
plan  of  treatment  has  not  been  a  success  and  has  since  been  discarded. 
Its  application  was  only  possible  in  that  class  of  cases  shown  in  Fig. 
688.  At  the  present  time  the  treatment  for  such  a  case  would  be  as 
described  for  the  following  case  (Fig.  691). 

Fig.  691,  a  mesioclusion,  or  a  Class  III  case,  is  from  a  younger  pa- 
tient than  the  one  shown  in  Fig.  688,  and  is  one  that  was  treated  with 
an  intermaxillary  anchorage.  It  will  be  seen  that  the  mandibular  teeth 
are  mesial  to  the  maxillary  teeth  the  width  of  one  premolar.  The  max- 
illary anterior  teeth  are  lingual  to  the  mandibular  teeth. 


480  PRACTICAL    ORTHODONTIA 

The  case  demands  the  expansion  of  the  upper  arch  and  the  distal 
movement  of  the  lower  teeth. 

After  having  placed  wire  on  the  mesial  and  distal  side  of  the  first 
molar  to  procure  the  necessary  separation,  clamp-bands  are  fitted  to 
the  teeth  with  the  screw  and  the  tube  occupying  the  proper  relation. 
The  upper  expansion  arch  is  placed  on  the  maxillary  teeth,  as  shown 


Fig.  692. — Mesioclasion,  or  Class  HI,  case.     Upper  and  lower  appliances  in  place. 

in  Fig.  692.  Spurs  may  be  soldered  to  the  anterior  part  of  the  arch 
(Fig.  694)  so  as  to  hold  the  maxillary  anterior  teeth  stationary  or  per- 
pendicular, thus  giving  more  resistance  to  the  maxillary  teeth,  which 
is  needed  to  move  the  mandibular  teeth  distally.  With  all  of  the  max- 
illary teeth  ligated  to  the  expansion  arch,  we  have  firm  anchorage. 


TREATMENT    OF    CASES  481 

However,  the  resistance  of  the  maxillary  teeth  to  forward  movement 
can  be  increased  by  bending  and  springing-  the  upper  alignment  wire. 
In  adjusting  the  alignment  wire  on  the  maxillary  teeth,  the  tubes  are 
so  aligned  that  the  anterior  portion  of  the  arch  occupies  a  position 
high  on  the  gingival  portion  of  the  teeth,  as  shown  in  Fig.  695.  Then, 
by  springing  the  arch  occlusally  and  wiring  it  to  the  teeth,  a  backward 


Fig.  693. — Position  of  lower  arch,  showing  intermaxillary  anchorage. 


Fig.   694. — Spurs   to   produce   bodily   movement   of  anterior  teeth   and   to   make   stationary   anchor- 
age of  teeth  in  upper  arch  to  move  mandibular  teeth  distally  in   Class  III. 

force  is  brought  to  bear  on  the  upper  molars  (Fig.  695).  If  the  arch 
should  be  left  this  way  without  any  counteracting  force,  the  maxillary 
molars  would  be  tipped  distally.  However,  in  mesioclusion,  or  Class 
III,  cases  the  maxillary  molars  are  prevented  from  moving  distally  by 
the  pull  of  the  intermaxillary  rubbers,  which  exert  a  forward  pull  on 
the  maxillary  teeth.  As  a  result  of  the  spring  of  the  arch  that  exerts 
a  backward  tipping  on  the  molars,  and  the  forward  pull  of  the  inter- 
maxillary rubbers,  the  maxillary  teeth  remain  stationary  and  become 
the  anchorage  that  moves  the  mandibular  teeth. 


482 


PRACTICAL   ORTHODONTIA 


In  adjusting  the  alignment  wire  to  move  the  lower  teeth  distally, 
the  anterior  position  of  the  arch  does  not  rest  against  the  lower  an- 
terior teeth.  This  is  because  we  desire  to  exert  all  of  the  force  upon 
the  mandibular  molars  and  move  them  distally  first.  The  position  of 
the  lower  arch  is  shown  in  Fig.  692.  No  ligatures  are  placed  on  the 
mandibular  anterior  teeth,  for  all  of  the  force  is  to  be  exerted  on  the 
mandibular  molars.     With  all  of  the  force  exerted  against  the  man- 


Fig.    695. — Position   of  arch  high   on   gingival   portion    of   teeth   to   make    stationary    anchorage   on 
molars  when  arch  is  sprung  down  as  shown  in  Fig.  696. 


Fig.   696. — Upper  arch  bent  occlusally  and  wired  to  make  molars  stationary. 


dibular  molars,,  they  will  be  moved  distally,  and  in  the  majority  of 
cases  the  premolars  will  follow  them.  In  the  treatment  of  the  case, 
as  the  molars  move  distally  and  a  space  is  left  between  the  molars 
and  premolars,  a  wire  ligature,  as  shown  in  Fig.  697,  is  placed  around 
the  first  premolar  and  attached  distally  to  the  tube  on  the  molar  band. 
This  ligature  can  be  tightened  and  a  stress  exerted  upon  the  premo- 


TRKATMENT    OF    CASES 


483 


lars,  which  brings  them  toward  the  molar.  Spurs  may  be  placed  on  the 
arch  slightly  distally  to  the  premolars,  and  each  tooth  ligated  to  the 
arch;  then,  by  screwing-  the  nut  on  the  lower  expansion  arch  forward 
to  such  position  that  it  does  not  rest  against  the  tube,  the  pull  of  the 
intermaxillary  rubber  moves  the  mandibular  premolars  distally.  This 
application  of  the  alignment  wire  is  shown  in  Fig.  698.  As  the  molars 
and  premolars  move  distally,  it  is  then  possible  to  place  wires  on  the 
canines  and  expand  in  the  canine  region.  Spurs  can  be  placed  on  the 
lower  arch  in  such  positions  as  to  exert  a  distal  pull  on  those  teeth. 
After  the  teeth  are  moved  into  the  proper  position,  the  maxillary  teeth 
are  retained  by  placing  plain  bands  on  the  molars  and  premolars,  with 


Fig.    697. — Application   of   ligature   around   premolars   and   distal    end    of   molar   tube   to    move 

premolars   distally. 


a  wire  soldered  to  the  lingual  surface  of  the  bands.  On  the  mesio- 
buccal  angle  of  the  molar  bands  (Fig.  699)  a  spur  is  soldered  to  engage 
the  intermaxillary  rubber  to  lie  used  in  retention.  On  the  mandibular 
teeth  plain  bands  are  made  for  the  molars  and  canines.  A  wire  is 
placed  on  the  labial  side  of  the  incisors  and  soldered  to  the  labial  sur- 
face of  the  canine  bands,  as  shown  in  Fig.  700.  A  wire  is  soldered  on 
the  lingual  side  of  the  molars  and  canines.  On  the  disto-labial  angle 
of  the  canine  band  a  spur  is  soldered,  engaging  the  intermaxillary  rub- 
ber that  extends  from  the  spur  soldered  to  the  maxillary  molar  bands. 
The  wearing  of  the  intermaxillary  rubbers  maintains  the  mesio-distal 
relation  of  the  teeth. 


484 


PRACTICAL   ORTHODONTIA 


Fig.  69S. — Spur  soldered  to  arch  to  engage  ligature  that  holds  premolar  to  arch  and  causes  it  to 
move  distally  as  a  result  of  the  intermaxillary  anchorage. 


Fig.    699. — Upper  retainer  for   mesioclusion,   or   Class   III. 


TREATMENT   OF    CASES  485 

In  the  treatment  of  niesioclusion,  or  Class  III,  eases,  there  is  a  great 
tendency  to  elongate  the  molars,  both  the  upper  and  lower.  However, 
the  greater  danger  lies  with  the  mandibular  molars,  owing  to  the 
manner  in  which  the  stress  is  brought  to  bear  on  those  teeth.  There- 
fore, the  teeth  must  not  be  moved  too  fast,  as  the  slow  movement  of 
the  teeth  prevents  the  elongation. 

Figs.  701  and  702  show  another  ease  of  mesioclusion,  or  Class  III, 
that  was  complicated  by  open-bite.  An  attempt  had  been  made  to 
correct  the  open-bite  by  extracting  the  second  and  third  mandibular 
molars  and  by  grinding  off  the  occlusal  surface  of  the  mandibular  first 
molars.    The  lower  molars  are  in  buccal  occlusion  and  the  upper  arch 


Fig.   700. — Showing   intermaxillary  retention  of  mesioclusion,   or  Class    III. 

is  slightly  narrow.  There  is  very  little  malocclusion  of  the  upper 
teeth.  The  lower  anterior  teeth  are  slightly  bunched  and  are  inclining 
lingually.  With  the  lingual  inclination  of  the  mandibular  teeth  it  be- 
comes necessary  to  move  the  apex  of  the  teeth  as  Avell  as  the  crowns, 
or  the  tipping  will  be  more  noticeable. 

The  expansion  arch  was  placed  on  the  maxillary  teeth,  as  shown  in 
Fig.  703,  all  of  the  teeth  being  ligated  to  the  arch  in  order  to  make  the 
upper  teeth  as  rigid  as  possible.  As  the  mandibular  molars  were  in 
buccal  occlusion,  the  expansion  arch  was  adjusted  with  an  active 
spring  force  toward  the  lingual  in  the  molar  regions.  The  relation  of 
the  ends  of  the  expansion  arch  to  the  molar  bands  is  shown  in  Fig. 


486 


PRACTICAL   ORTHODONTIA 


Fig.    701. 


Fig.   702. 
Figs.    701    and    702 — Mesioclusion,    or    Class    III,    case.      Open-bite    and    narrow    upper    arch. 


TREATMENT   OF    CASES  487 

704.  When  the  expansion  arch  is  inserted  in  the  tubes  on  the  molar 
bands,  a  lingual  force  will  be  exerted  on  the  teeth  that  will  narrow  the 
distal  portion  of  the  dental  arch.  In  putting  the  expansion  arch  in 
the  tubes  where  a  lingual  force  is  exerted  on  the  molars,  it  is  always 


Fig.    703. — Upper   teeth   ligated   to   make   stationary   anchorage   in   molar    region. 


Fig.    704. — Shows    how   arch    was    bent    to    move    mandibular   molars    lingually. 

necessary  to  tie  the  arch  in  place,  for  the  lingual  spring  will  throw  the 
arch  out  of  the  tubes.  While  the  mandibular  molars  are  being  moved 
lingually,  the  intermaxillary  rubbers  are  worn  from  the  hooks  that 
were  placed  on  the  lower  arch  in  the  region  of  the  canines  to  the  tubes 


488 


PRACTICAL    ORTHODONTIA 


on  the  maxillary  molar  bands.  After  studying  the  ease,  it  was  de- 
cided to  elongate  the  mandibular  incisors  in  order  to  close  the  open- 
bite.  Therefore,  the  lower  expansion  arch  occupied  a  position  along 
the  incisal  border  of  the  teeth.  Wire  ligatures  were  placed  around  the 
teeth  and  twisted  tightly  to  prevent  them  from  slipping  over  the  gin- 
gival marginal  ridge  of  the  teeth;  then  the  ends  of  the  wires  were 
brought  around  the  arch  and  twisted.    This  springs  the  expansion  arch 


Fig.   70S. — Ends   of  lower   arch   in   tubes   and   ligated   in   place. 


Fig.    706. — Showing    spurs    on    lower   arch    to    keep    mandibular    teeth    upright. 


gingivally  and  exerts  a  force  on  the  mandibular  teeth  so  as  to  elongate 
them.  In  order  to  keep  the  mandibular  teeth  in  their  upright  position 
and  to  move  the  apex  of  the  teeth  distally,  spurs  are  soldered  to  the 
lower  arch,  as  shown  in  Fig.  706.  The  mandibular  anterior  teeth 
should  be  elongated  to  very  nearly  the  desired  length  before  they  are 
ligated  to  the  arch  and  spur;  for,  in  order  that  the  spur  will  be  effec- 


TREATMENT   OF    CASES 


489 


Fig.   707. — Side  view   with   intermaxillary   anchorage. 


Fig.   708. — Front  view  with  intermaxillary   anchorage. 


I!lll 


PRACTICAL    ORTHODONTIA 


tive,  it  is  necessary  to  use  a  plain  ligature  that  will  hold  the  tooth 
tightly  to  the  spur.  A  small  piece  of  rubber  can  then  be  placed  under 
the  gingival  end  of  the  spur,  and  the  apex  of  the  teeth  will  be  carried 
lingually.    Figs.  709  and  710  illustrate  the  side  and  front  views  of  the 


Fig.   709. 


Fig.    710. 
l-'ik'>.    709   and   710. — Result   of   treatment    of    case   shown    in    Fin*.    701    and   702. 


TREATMENT    OF    CASES 


491 


case  at  the  time  the  regulating  appliance  was  removed  and  a  retainer 
placed  on  the  teeth.     The  rear  view  (Figs.  711  and  712)  shows  how 


Fig.   711. 


Fig.    712. 

Figs.   711   and  71-?. — Showing  effect  of  moving  lower  molars  lingually.      Fig.   711,  before  treatment; 

Fig.  712,  after  treatment. 


much  the  region  of  the  lower  molars  was  narrowed.     The  retaining 
appliances  are  the  same  as  those  described  in  the  previous  case,  with 


492  PRACTICAL    ORTHODONTIA 

the  addition  of  small  spurs  on  the  lingual  side  of  the  lower  labial  wire, 
which  engage  the  approximal  sides  of  the  lower  teeth.  These  spurs 
keep  the  teeth  in  their  proper  position,  oceluso-gingivally.  Inter- 
maxillary rubbers  are  worn  to  keep  the  teeth  in  their  proper  mesio- 
distal  relation,  extending  from  the  spur  on  the  maxillary  first  molars 
to  the  mandibular  canines. 

For  the  purpose  of  producing  a  distal  movement  of  the  apices  of  the 
mandibular  incisors  in  mesioclusion,  or  Class  III,  cases,  the  pin-and- 
tube  appliance  is  very  desirable,  as  the  pins  can  be  adjusted  to  produce 
an  apical  movement.  In  order  to  increase  the  action  of  the  pin  and  to 
give  it  a  greater  range  of  elasticity,  the  pin  can  be  extended  and  bent 
in  the  form  of  a  hook  (Fig.  713)  and  placed  in  the  tube  from  the 
occlusal  side.  This  application,  which  was  suggested  by  Lourie,  al- 
lows the  labial  arch  to  be  out  of  sight,  as  it  is  entirely  covered  by  the 
lip,  which  is  a  great  advantage  over  the  old  form  where  the  arch 
occupied  a  position  near  the  occlusal  edge  of  the  teeth.  Lingual 
arches  can  also  be  employed  in  a  great  many  cases  of  mesioclusion 
and  offer  the  same  advantages  that  they  do  in  other  types  of  mal- 
occlusion, namely,  delicacy  and  inconspicuousness. 

Fig.  714  is  a  case  of  mesioclusion  in  a  patient  of  advanced  age  who 
was  very  sensitive  in  regard  to  having  any  appliances  show.  Plain 
bands  were  placed  on  the  maxillary  first  molars  carrying  small  tubes 
for  the  purpose  of  receiving  the  ends  of  the  lingual  arch,  which  was 
held  in  place  by  a  lock  similar  to  the  others  described  in  the  construc- 
tion of  lingual  arches.  Plain  bands  were  also  placed  on  the  mandibu- 
lar molars  and  the  lingual  arch  was  soldered  to  the  bands.  On  the 
buccal  surface  of  the  mandibular  molar  bands,  was  soldered  an  exten- 
sion for  the  purpose  of  receiving  the  intermaxillary  ligature.  The  ex- 
tension is  shown  in  Fig.  716.  A  small  spur  was  soldered  on  the  buc- 
cal surface  of  the  upper  molar  band  to  engage  the  intermaxillary 
rubber  that  extended  to  the  buccal  extension  of  the  lower  molar.  By 
pinching  the  upper  lingual  wire,  the  necessary  expansion  was  pro- 
duced. The  change  in  the  mesio-distal  relation  of  the  arches  is  shown 
by  comparing  Fig.  714  with  Fig.  715.  This  appliance  can  be  made  less 
bulky  and  less  conspicuous  by  attaching  the  intermaxillary  rubber  to 
the  lingual  arches,  as  Lourie  is  doing  with  later  cases. 

Unilateral  Mesioclusion,  or  Class  III,  Subdivision 

Figs.  717  and  718  show  a  case  of  the  unilateral  mesioclusion,  or 
Subdivision  of  Class  III.  The  dental  arches  are  normal  mesio-distally 
on  one  side,  and  mesial  on  the  right.    In  looking  at  the  front  view  of 


TREATMENT   OF    CASES 


493 


Fig.  713. — Spring  extension  to  be  used  for  apical  movement  in  mesioclusion  cases. 


Fig.  714. 


Fig.  715. 


Fig.  716. 
Figs.   714,   715   and  716. — Case  of  mesioclusion  treated  by  the   use   of  lingual  arches.      (Lourie.) 


494  practical  Orthodontia 

the  case,  it  will  be  seen  that  the  upper  lateral  incisors  are  in  lingual 
occlusion.     The  palatal  view  (Figs.  71!)  and  720)  shows  great  contrac- 


Fig.    717. — Normal    mesiodistal    side    of    unilateral    mesioclusion,    or    Class    III,    Subdivision    case. 


Fig.  718. — Front  view  of   Class  III,   Subdivision  case. 

tiou  or  rather  lack  of  development  of  the  upper  dental  arch,  all  of  the 
molars  and  premolars  being  in  lingual  occlusion. 


TREATMENT    OP    CASUS  495 

In  applying-  the  expansion  arch  to  the  maxillary  teeth,  clamp  bands 
are  placed  on  the  maxillary  first  molars  after  separation  has  been 
gained  by  the  use  of  a  ligature  wire.  The  bands  are  so  adjusted  that 
the  tubes  will  occupy  a  position  that  will  enable  the  arch  to  lie  near 
the  gingival  portion  of  the  teeth.  The  expansion  arch  in  the  canine  re- 
gion is  left  rather  square,  as  shown  in  Fig.  719,  as  the  canines  must  be 
moved  buccally.  Soft-solder  spurs  are  placed  on  the  arch  buccally 
to  the  canines  so  that  it  will  be  possible  to  move  these  teeth  directly 
buccally.  Before  the  arch  is  placed  in  the  tubes  on  the  molar  bands, 
the  ends  of  the  expansion  arch  should  occupy  a  position  to  the  tubes 
as  shown  in  Fig.  723.  If  the  distal  part  of  the  arch  is  farther  buccally 
to  the  tube  than  is  the  mesial  part,  the  tooth  will  be  rotated.  The 
canines  and  premolars  are  ligated  to  the  arch  and  after  the  canines 
have  been  moved  slightly,  or  enough  to  make  some  space,  the  ligatures 
are  placed  on  the  lateral  and  they  are  moved  into  position. 

Clamp-bands  are  placed  on  the  mandibular  first  molars  and  the  tubes 
are  so  placed  that  they  will  permit  the  arch  to  occupy  a  position  near 
the  gingival  border  of  the  teeth.  As  it  is  necessary  to  move  the  lower 
teeth  on  the  right  side  distally,  an  intermaxillary-hook  is  soldered  to 
the  lower  arch  opposite  the  right  canine.  An  intermaxillary-hook 
should  also  be  placed  on  the  left  side  of  the  arch  opposite  the  canine, 
not  to  move  the  mandibular  teeth  distally,  but  to  be  used  to  reenforce 
the  maxillary  molar,  for  in  moving  the  maxillary  left  lateral  over  the 
mandibular  teeth  the  upper  molar  is  sometimes  forced  distally.  With 
the  intermaxillary-hook  on  the  lower  arch,  an  intermaxillary  rubber 
can  be  used  to  prevent  such  occurrence.  The  anterior  portion  of  the 
lower  expansion  arch  stands  away  from  the  teeth,  and  the  intermaxil- 
lary ligatures  exert  all  of  the  force  on  the  mandibular  right  molar. 
No  rubber  ligature  is  placed  on  the  left  side,  unless  it  is  necessary  to 
reenforce  the  maxillary  molar  anchorage.  After  the  mandibular  mo- 
lars begin  to  move  distally,  if  a  space  is  developed  between  the  molars 
and  premolars,  ligatures  should  be  put  on  those  teeth  to  move  them 
distally,  after  the  manner  described  in  the  treatment  of  the  full  divi- 
sion. The  author  does  not  consider  it  at  all  advisable  to  allow  the 
molars  to  be  moved  away  from  the  premolars  any  distance;  for  it  de- 
stroys the  approximal  contact  of  the  teeth,  disturbs  the  fibers  of  the 
peridental  membrane  that  run  from  the  cementum  of  one  tooth  to  the 
cementum  of  the  other,  and  makes  retention  more  difficult.  The  lower 
right  canine  must  also  be  moved  in  turn  as  the  molars  are  moved.  The 
author  wishes  it  distinctly  understood  that  he  does  not  advocate 
starting  all  of  the  mandibular  teeth  on  one  side  at  once;  but  as  soon 


496 


PRACTICAL    ORTHODONTIA 


Fig.   719. — Occlusal  view  with  upper  arch  adjusted. 


Fig.  720. — Occlusal  view  with  lower  arch  adjusted. 


TREATMENT   OF    CASES 


497 


Fig.   721. 


Fig.  722. 
Figs.   721  and  722. — Side  views  showing  intermaxillary  anchorage  used  on  mesial  side  of  lower. 


498 


PRACTICAL    ORTHODONTIA 


as  there  has  been  sufficient  tissue  change  around  the  molars  so  that 
they  will  start  to  move,  the  premolars  and  the  canine  must  have  force 
brought  to  bear  on  them  in  order  that  they  will  move  distally  together 
and  hold  the  teeth  in  their  proper  approximal  relations..  After  the  mo- 
lars, premolars  and  canines  have  been  moved  to  their  proper  place,  or 
nearly  so,  the  anterior  mandibular  teeth  can  then  be  moved  to  the 
desired  position. 

The  retention  of  the  maxillary  teeth  consists  in  the  use  of  the  plain 
bands  on  the  first  molars  and  canines  with  a  lingual  retaining  wire 
soldered  to  the  bands.     On  the  mesio-buccal  angle  of  the  upper  molar 


Fig.    723. — Application    of    arch    to    expand    molars    without    rotating    same. 


band,  a  spur  is  soldered  that  will  engage  a  rubber  ligature  to  be  used 
for  intermaxillary  retention.  The  lower  retainer  in  this  case  will  con- 
sist of  the  same  device  as  was  used  in  the  bilateral  case  (Fig.  700), 
except  that  on  the  mandibular  left  canine  band  no  spur  is  soldered  on 
the  disto-labial  angle  to  engage  the  intermaxillary  rubber. 

As  the  teeth  become  locked  by  the  inclined  planes  and  the  ap- 
proximal relation  of  the  contact  point,  the  wearing  of  the  rubbers  can 
be  discontinued  gradually. 

Since  the  treatment  of  any  one  case  of  the  subdivision  is  very  much 
the  same  as  any  other,  these  cases  need  not  be  discussed  further  here ; 
however,  it  must  be  remembered  that  the  cases  of  this  particular  type 
are  generally  progressive,  and  both  the  division  and  the  subdivision 
should  receive  early  attention. 


CHAPTER  XII 

MALOCCLUSION  AND  NASAL  DEFORMITIES 

It  has  long  been  recognized  that  there  is  a  relation  existing  be- 
tween malocclusion  of  the  teeth  and  deformities  of  the  nasal  cavity, 
but  there  has  been  some  dispute  in  regard  to  what  relation  one  has  to 
the  other  and  which  is  the  causative  factor  and  which  is  the  effect. 
In  considering  the  etiology  of  malocclusion,  we  have  learned  that  a 
certain  number  of  malocclusions  are  caused  by  mouth-breathing,  which 
is  produced  by  abnormal  forces  of  occlusion  that  result  from  a  dis- 
turbed function  of  the  muscles  and  abnormal  atmospheric  pressure. 
It  has  also  been  observed  that  associated  with  certain  types  of  maloc- 
clusion we  almost  invariably  have  certain  types  of  nasal  deformity. 
It  has  long  been  recognized  that  there  are  certain  types  of  nasal  de- 
formities associated  with  certain  malocclusions  that  cannot  be  im- 
proved to  any  great  extent,  unless  the  treatment  is  in  conjunction  with 
the  correction  of  malocclusion. 

There  are  a  certain  number  of  individuals  who  are  suffering  from 
mouth  breathing  in  which  the  month-breathing  has  undoubtedly  been 
caused  by  hypertrophy  of  the  lymphoid  tissue  in  the  naso-pharynx, 
and  upon  removal  of  this  lymphoid  tissue  the  mouth-breathing  still 
persists.  This  is  because  the  abnormal  action  of  the  muscles  and  ab- 
normal atmospheric  pressure  during  the  time  the  individual  has  been 
a  mouth-breather  has  produced  a  malocclusion  and  along  with  the 
malocclusion  has  been  produced  a  deformity  or  abnormal  develop- 
ment of  the  nasal  cavity.  We  are  then  natural ly  confronted  by  the 
question  as  to  what  relation  exists  between  malocclusion  of  the  teeth 
and  deformed  nasal  cavities,  which  is  the  causative  factor  and  which 
is  the  effect,  and  what  benefit  can  be  expected  to  be  derived  from  the 
correction  of  malocclusion  so  far  as  the  deformed  nasal  cavity  is  con- 
cerned. Considering  the  relation  between  malocclusion  and  deformed 
nasal  cavities,  it  is  well  to  remember  the  anatomy  of  the  parts  con- 
cerned. It  must  be  remembered  that  the  nasal  and  oral  cavities  as  we 
find  them  in  the  adult,  have  at  one  time  been  a  common  cavity,  which 
may  be  described  from  an  embryologic  standpoint  as  consisting  of  a 
single  opening  at  the  anterior  end  of  the  alimentary  canal  which  is 
known  as  a  stomodium.  We  must  also  bear  in  mind  the  fact  that  in 
the  early  life  of  the  individual,  the  nasal  and  oral  cavities  are  one  cav- 

499 


500  PRACTICAL    ORTHODONTIA 

ity  without  any  separating  structure,  or,  in  other  words,  the  hard  and 
soft  palate  has  not  yet  developed  to  separate  the  nasal  from  the  oral 
cavity. 

In  the  development  of  the  nasal  and  oral  cavity,  we  find  that  the  first 
branchial  arch  and  the  fronto-nasal  process  play  a  very  important 
part.  The  first  branchial  arch  divides  into  two  parts:  one  of  which  is 
known  as  the  mandibular  portion  and  is  the  lower  part,  and  the  upper 


Fig     7^4— Drawing    showing   embryonic    devel-       F'g-    725.— Cross    section    of    developing    nasal 
opment     of     roof     of    mouth.       (His.)  and   oral   cavity   of   embryo    pig.      (His.) 


Fig.    726. — Cross   section   of   developing   nasal   cavity   after   the    union    of   the   palatal   processes   of 

the   superior  maxilla?.      (His.) 

part  known  as  the  maxillary  portion  which  grows  from  the  superior 
right  and  left  side  of  the  mandibular  arch  and  finally  unites  with  the 
frontal-nasal  bud  in  that  region  that  may  be  compared  to  the  lip  or 
alveolar  border.  From  the  inner  posterior  part  of  the  first  branchial 
arch  there  grows  off  a  shelf  or  offshoot,  which  finally  unites  in  the  me- 
dian line  that  forms  the  hard  and  soft  palate.  It  is  a  formation  of  the 
hard  and  soft  palate  that  separates  the  nasal  from  the  oral  cavity. 


MALOCCLUSION    AND   NASAL   DEFORMITIES  501 

The  development  of  these  parts  can  be  observed  in  Fig.  724,  which 
is  copied  after  His.  Another  structure  or  development  that  we  must 
consider  in  relation  to  malocclusion  and  deformity  of  the  nasal  cavity 
is  the  development  of  the  nasal  septum,  the  turbinated  body  shown  in 
Fig.  725.  Growing  downward  from  the  base  of  the  cranium  or  from  the 
chondro-cranium  we  have  a  cartilaginous  structure,  or  rather  structures, 
which  make  up  or  contribute  to  what  is  known  in  later  life  as  the  nasal 
septum.  Growing  down  from  the  horizontal  plate  of  the  ethmoid  we 
have  the  perpendicular  plate  of  the  ethmoid,  which  grows  downward 
into  the  nasal  cavity  toward  the  median  line  or  the  junction  of  the  hard 
palate.  From  the  base  of  the  sphenoid,  we  find  another  cartilaginous 
structure  that  grows  forward,  which  is  known  as  the  cartilaginous  vo- 
mer. It  is  later  replaced  by  intramembranous  bones  developing  on  the 
right  and  left  side  of  the  cartilage.  Associated  with  the  perpendicular 
plate  of  the  ethmoid  and  the  vomer  we  have  a  cartilage  known  as  the 
triangular  cartilage,  which  completes  what  is  later  known  in  life  as  the 
nasal  septum.  The  downward  growth  of  the  perpendicular  plate  of  the 
ethmoid  and  the  vomer  occurs  regardless  of  the  development  of  the  lat- 
eral halves  of  the  nasal  cavity.  It  occurs  regardless  of  the  develop- 
ment of  the  floor  of  the  nose  and  it  is  this  factor  that  must  be  kept  in 
mind  in  considering  the  relation  of  the  deformity  of  the  nasal  cavity  in 
relation  to  malocclusion.  As  the  nasal  septum  grows  downward  from 
the  chondro-cranium,  the  horizontal  plate  of  the  superior  maxillary 
bone,  which  has  been  developed  in  the  maxillary  bud  of  the  first  bran- 
chial arch,  grows  toward  the  median  line  and  the  structures  unite  at  the 
median  line  forming  the  floor  of  the  nose,  the  nose  being  divided  by  the 
nasal  septum  into  the  right  and  left  nares.  The  embryonic  development 
of  the  nasal  septum  and  the  floor  of  the  nose  is  shown  in  Fig.  726.  Fig. 
727  is  a  posterior  view  of  the  maxillary  bone  and  the  mandible,  show- 
ing the  bony  wall  of  the  oral  cavity  and  the  nasal  cavity  as  viewed  from 
the  posterior  border.  It  will  be  seen  that  the  hard  palate  or  the  roof  of 
the  mouth  also  forms  the  floor  of  the  nose,  that  the  right  and  the  left 
half  of  the  nares  is  made  up  by  the  perpendicular  plate  of  the  superior 
maxillary  bone  or  the  nasal  process  of  the  superior  maxillary,  while  the 
superior  lateral  wall  of  the  nose  is  made  up  of  the  lateral  mass  of  the 
ethmoid. 

The  horizontal  plate  of  the  ethmoid,  assisted  by  a  small  part  of  the 
frontal  and  body  of  the  sphenoid  bone,  forms  the  roof  of  the  nose.  It 
then  gives  us  the  nasal  cavity  completely  surrounded  by  a  bony  struc- 
ture and  separated  by  the  nasal  septum.  The  nasal  cavity  is  separated 
into  the  right  and  left  nares  by  the  nasal  septum,  which  has  grown 


502 


PRACTICAL    ORTHODONTIA 


downward  from  the  perpendicular  plate  of  the  ethmoid,  the  body  of 
the  sphenoid,  and  which  grows  toward  the  roof  of  the  mouth  in  the  me- 
dian line.  The  nasal  septum  is  primarily  of  cartilaginous  origin  and  is 
replaced  by  an  osseous  structure.  Physiologically  the  nasal  septum  has 
nothing  to  do  with  respiration.  From  an  evolutionary  standpoint  the 
vomer  was  originally  a  tooth-bearing  bone  and  has  been  walled  off  in 
the  nasal  cavity  during  the  process  of  evolution. 


Fig.    727. — Posterior  view   of   nasal   cavity   showing  bony   cavity   which   contains   the   nasal   septum. 


As  we  study  this  question  further,  we  find  that  the  factors  that  affect 
the  development  of  the  lateral  walls  of  the  nasal  cavity  and  the  floor  of 
the  nasal  cavity  do  not  necessarily  affect  the  septum.  As  a  result  of 
this,  we  find  certain  types  of  malocclusion  in  which  the  nasal  cavity 
does  not  develop  as  rapidly  as  it  should.  The  nasal  septum  will  continue 
to  grow  downward  and  as  it  meets  witli  resistance  from  the  floor  of  the 
nose  will  become  deflected.  Fig.  728  is  a  diagram  showing  the  various 
parts  of  the  nasal  septum,  of  which  T  C  is  a  triangular  cartilage,  E  is 
the  perpendicular  plate  of  the  ethmoid,  and  V  the  vomer.     It  will  be 


MALOCCLUSION   AND    NASAL   DEFORMITIES  503 

observed  that  the  vomer  grows  downward  and  forward  originally  in 
cartilage,  and  is  later  replaced  by  intermembranons  bone  development 
on  both  sides  of  the  cartilage,  and  the  cartilage  disappears.  The  vomer 
may  thus  be  considered  a  double  structure  composed  of  a  right  and  a 
left  side.  The  perpendicular  plate  of  the  ethmoid  grows  downward 
from  the  horizontal  plate  of  the  ethmoid  and  joins  the  vomer  and  the 
triangular  cartilage.  The  anterior  part  of  the  nasal  septum  is  completed 
by  the  triangular  cartilage,  which  is  also  subject  to  a  great  many  defor- 
mations that  may  be  the  result  of  abnormal  development  of  the  nasal 
cavity  as  the  result  of  injury.  An  examination  of  Fig.  728  will  show  that 
the  nasal  septum  is  enclosed  between  two  bony  walls  or  surfaces,  which 
are  the  roof  of  the  nose  and  the  floor  of  the  nose.  The  distance  be- 
tween the  floor  of  the  nose  and  the  roof  of  the  nose  is  dependent  upon 


Fig.    728. — Diagram   of  nasal   septum.      T.C..  Triangular   cartilage;   E.,  Perpendicular  plate   of   eth- 
moid;   V.,    Vomer. 

the  development  of  the  lateral  wall  of  the  nose,  the  principal  part  of 
which  is  the  superior  maxillary  bone.  Therefore,  if  any  condition  arises 
that  interferes  with  the  growth  of  the  superior  maxillary  bone,  it  neces- 
sarily will  cause  a  shortening  between  the  floor  of  the  nose  and  the  roof 
of  the  nose.  The  nasal  septum  will  be  compelled  to  occupy  a  smaller 
space  than  it  was  originally  intended  to  occupy. 

It  is  also  a  fact  that  conditions  that  affect  the  development  of  the 
lateral  wall  of  the  nose  do  not  affect  the  nasal  septum.  Therefore,  in 
a  great  many  types  of  malocclusion  we  find  that  deflected  nasal  septi 
are  the  result  of  the  lack  of  development  of  the  lateral  walls  of  the 
nasal  cavity  and  the  superior  maxillary  bone,  which  have  resulted  in 
a  lack  of  distance  between  the  roof  of  the  nose  and  the  floor  of  the  nose. 


504 


PRACTICAL    ORTHODONTIA 


Fig.  729  shows  a  fetal  skull  at  birth,  and  at  this  time  the  bony  septum 
or  nasal  septum  is  enclosed  in  the  bony  walls  of  the  nasal  cavity.  It  will 
also  be  observed  that  the  roof  of  the  mouth  is  comparatively  flat;  that 
the  alveolar  process  is  close  to  the  orbital  cavity;  and  that  there  must 
be  great  increase  in  distance  between  the  floor  of  the  orbital  cavity  and 
the  alveolar  process  as  the  individual  develops.  The  inferior  turbi- 
nated bone  is  very  close  to  the  roof  of  the  mouth  or  floor  of  the  nose, 
with  the  result  that  as  the  individual  grows,  the  nasal  cavity  increases 


Fig.   729.- — Nasal  septum  enclosed   in   nasal  cavity. 


in  length,  especially  between  the  inferior  turbinated  bone  and  the  floor 
of  the  nose. 

As  this  floor  of  the  nose  is  carried  downward  by  the  development  of 
the  lateral  walls,  space  is  made  for  the  nasal  septum,  and  if  develop- 
ment goes  on  harmoniously  we  find  that  a  development  occurs  in  the 
adult  that  is  the  same  as  we  find  in  Fig.  730.  From  above  downward 
there  is  a  tendency  for  the  nasal  septum  to  separate  into  two  parts, 
showing  the  tendency  for  the  organ  to  be  developed  into  a  right  and  a 
left  part. 


MALOCCLUSION    AND    NASAL   DEFORMITIES 


505 


Fig.  731  is  the  posterior  part  of  Fig.  730  and  it  shows  the  shape  of 
the  roof  of  the  mouth,  which  is  a  beautiful  arch,  by  the  development 
of  the  maxillary  sinuses  and  the  increased  distance  between  the  turbi- 
nated bones  and  the  floor  of  the  nose.     This  skull  may  be  considered 


Fig.  730. — Nasal  cavity  of  an  adult. 


as  showing  a  normal  development  and  as  one  in  which  there  is  a  normal 
nasal  cavity  associated  with  what  was  a  normal  occlusion.  In  certain 
types  of  malocclusion,  which  may  be  neutroclusion,  or  Class  I,  com- 


506 


PRACTICAL    ORTHODONTIA 


plicated  by  lack  of  development  of  the  dental  arches,  or  which  may 
be  distoclusion  complicated  by  labioversion  of  the  upper  incisors  (Class 
II,  Division  1),  or  in  fact  in  any  individual  who  is  a  mouth-breather, 
we  are  very  apt  to  have  an  abnormal  development  of  the  nasal  cavity  be- 
cause of  the  abnormal   development  of  the  superior  maxillary  bone. 

If  the  lateral  walls  of  the  nasal  cavity  do  not  grow  downward  rapidly 
enough,  there  will  be  a  decrease  in  distance  between  the  floor  of  the  nose 


Fig.    731. — Showing  double   plates   of   nasal   septum. 


and  the  roof  of  the  mouth,  which  will  result  in  a  deflected  septum.  The 
removal  of  adenoids  does  not  benefit  this  condition,  because  the  only 
thing  that  will  restore  the  development  of  the  nasal  cavity  to  the  proper 
size  is  the  treatment  of  the  malocclusion  that  will  produce  the  proper 
growth  of  the  superior  maxillary  bone  and  result  in  changes  in  the  en- 
tire nasal  cavity.  It  has  long  been  recognized  by  the  many  authorities 
that  the  correction  of  the  malocclusion  always  produces  a  beneficial  re- 


MALOCCLUSION    AND    NASAL   DEFORMITIES  507 

result  in  the  deformity  or  lack  of  development  of  the  nasal  cavity.  This 
observation  has  led  to  several  plans  of  treatment,  some  of  which  are 
based  on  the  correction  of  malocclusion  only  with  the  resulting  change 
in  the  nasal  cavity,  while  other  plans  of  treatment  are  based  upon  the 
correction  of  the  malocclusion  with  the  idea  of  improving  the  nasal  cav- 
ity by  changing  the  shape  with  mechanical  interference. 

A  number  of  cases,  reported  several  years  ago  by  Ketchum,  showed 
that,  in  the  treatment  of  malocclusion  in  patients  who  were  mouth- 
breathers,  the  nasal  cavity  increased  very  materially  in  size  and  that 
deflected  septi  disappeared  or  improved  during  the  process  of  treat- 
ment. Observations  made  in  the  author's  practice  have  substantiated 
this  fact,  so  that  we  can  slate  that  the  correction  of  the  malocclusion 
in  the  young  individual,  when  the  superior  dental  arch  is  not  properly 
developed,  will  practically  remove  the  deflected  nasal  septum.  It  has 
also  been  observed  that  in  older  individuals  who  were  suffering  from 
nasal  stenosis  in  which  there  was  insufficient  space  in  the  nasal  cavity, 
especially  in  a  lateral  direction,  by  an  expansion  of  the  dental  arch  an 
increased  nasal  space  is  produced  and  normal  breathing  becomes  pos- 
sible. 

By  studying  Figs.  727,  730,  or  731  from  a  purely  mechanical  stand- 
point, it  will  be  seen  that  any  device  or  kind  of  treatment  that  will 
expand  the  dental  arch  and  expand  tin'  alveolar  process  of  the  superior 
maxillary  bone  will  necessarily  produce  some  change  in  the  width 
of  the  nasal  cavity.  The  change  in  the  width  of  the  nasal  cavity  can 
be  produced  in  several  ways.  It  must  be  remembered  that  the  teeth 
are  embedded  in  the  peridental  membrane,  which  is  a  continuation  of 
the  muco-periosteum  that  covers  the  floor  of  the  nose  and  the  roof  of 
the  mouth,  and  which  is  made  up  of  white  inelastic  fibers.  By  an  ex- 
pansion of  the  dental  arch,  stress  is  brought  to  bear  upon  the  fibers 
of  the  peridental  membrane,  which  in  turn  is  transmitted  to  the  peri- 
osteum covering  the  floor  of  the  nose  and  roof  of  the  mouth.  This 
exerts  an  influence  upon  the  floor  of  the  nose  to  such  an  extent  that 
the  shape  of  the  floor  of  the  nose  will  be  changed,  and  with  individuals 
who  have  high  narrow  arches  the  roof  of  the  mouth  will  be  changed  to 
one  which  is  wide  and  broad.  If  the  nasal  cavity  is  examined  in  these 
individuals  before  treatment  is  begun,  we  will  observe  that  either  the 
nasal  septum  is  deflected  or  there  is  a  lack  of  width  between  the  lateral 
walls  of  the  nose.  As  the  change  occurs  in  the  roof  of  the  mouth  and 
as  the  nasal  cavity  is  again  examined,  it  will  be  found  that  the  nasal 
septum  has  straightened  and  that  there  has  been  an  increase  in  width  be- 
tween the  lateral  walls  of  the  nose.     In  other  words,  there  has  been  a 


508  PRACTICAL   ORTHODONTIA 

change  in  the  roof  of  the  mouth  in  that  the  roof  of  the  mouth  has  be- 
come wider  and  has  come  farther  downward  from  the  base  of  the 
cranium. 

Some  of  this  change  in  the  roof  of  the  mouth  is  the  direct  result  of 
mechanical  pressure,  while  more  of  it  is  the  result  of  a  growth  pro- 
duced by  mechanical  stimulation,  and  the  result  of  cell  metabolism  and 
changes  in  the  structure  as  a  result  of  natural  growth.  It  must  be 
remembered  that  the  superior  maxillary  bone  is  a  bone  of  environment 
and  responds  to  mechanical  influences  and  stress;  and  that  by  chang- 
ing the  position  of  the  teeth  so  as  to  change  the  stress  upon  the  bone, 
the  entire  superior  maxillary  bone  will  be  changed  in  the  growing  indi- 
vidual. In  fact,  a  great  change  will  also  occur  in  older  individuals, 
which  has  been  observed  in  the  author's  practice.  The  cases  that 
Ketcham  reported  and  the  cases  observed  in  the  author's  practice  were 
changes  that  were  produced  by  ordinary  orthodontic  treatment  or  that 
were  the  result  of  slow  and  gradual  pressure  upon  the  teeth  without 
making  any  direct  effort  to  change  the  shape  of  the  maxillary  bone  as 
the  result  of  direct  mechanical  pressure. 

A  number  of  others  have  reported  cases  in  which  the  superior  max- 
illary bone  has  been  changed  in  shape  and  in  which  the  nasal  cavity 
has  been  changed  by  exerting  pressure  upon  the  teeth  and  the  superior 
maxillary  bone  with  the  idea  of  changing  the  shape  of  the  roof  of  the 
mouth  as  a  result  of  direct  mechanical  pressure.  This  treatment  has 
been  based  upon  the  idea  that  by  pressure  the  median  suture  between 
the  right  and  left  superior  maxillary  bones  could  be  opened,  and  as  the 
result  of  the  opening  of  this  suture  a  lateral  expansion  of  the  nasal 
cavity  would  occur. 

"While  the  author  has  never  followed  this  plan  of  treatment  in  active 
practice,  nevertheless  he  is  convinced  that  it  is  possible  to  open  the 
intermaxillary  suture  by  the  construction  of  special  appliances,  and 
in  fact,  it  may  be  done  in  some  cases  with  any  appliance.  The  author 
has  done  this  experimentally  upon  dogs  at  different  times  without  any 
seemingly  ill  effect  upon  the  dogs  and  with  the  result  that  the  bone 
has  filled  in  the  open  suture  and  the  nasal  cavity  has  been  increased 
in  width.  There  is  no  question  but  what  there  are  extreme  cases  of 
nasal  stenosis,  narrow  dental  arches  with  high  palate,  in  which  it  is 
desirable  to  construct  some  style  of  appliance  especially  suited  to  widen 
the  lateral  halves  of  the  superior  maxillary  bone,  not  so  much  with  the 
idea  of  opening  the  median  suture  as  with  the  idea  of  producing  a 
bodily  movement  of  the  teeth  and  of  carrying  out  the  lateral  halves  of 
the  superior  maxillary  bone  as  much  as  possible.     This  can  be  pro- 


MALOCCLUSION    AND    NASAL   DEFORMITIES  509 

duced  by  constructing  appliances  that  consist  of  bands  placed  upon 
the  molars  and  the  canine  teeth,  or  upon  the  teeth  of  the  two  lateral 
halves  of  the  arches,  and  then,  by  the  use  of  alignment  wires  in  such  a 
manner  that  a  direct  buccal  pressure  is  exerted  upon  the  teeth,  they  are 
forced  to  move  bodily,  thereby  carrying  the  superior  maxillary  bone  or 
alveolar  process  with  them  in  a  bodily  direction. 

In  younger  individuals  who  have  only  the  deciduous  teeth,  or  decid- 
uous molars  and  permanent  molars,  the  construction  of  an  appliance 
for  the  purpose  of  producing  bodily  movement  is  very  unsatisfactory 
if  the  appliance  is  attached  directly  to  the  teeth,  because  it  will  loosen 
the  deciduous  teeth.  However,  we  find  that  the  cases  at  this  age  are 
the  most  desirable  for  treatment.  To  overcome  the  difficulty  encoun- 
tered with  loose  deciduous  teeth,  the  use  of  the  plate  has  been  employed 
to  exert  pressure  upon  the  alveolar  structures  through  the  soft  tissue. 

The  old  Coffin  split  plate  presented  some  advantages  in  the  treat- 
ment of  these  cases.  The  idea  has  later  been  modified  by  others,  in- 
cluding a  device  that  was  published  several  years  ago  by  Ottolengui, 
and  a  modification  of  a  common  split  plate  that  is  used  at  the  present 
time  by  Richardson.  As  a  result  of  the  use  of  this  appliance  the  pa- 
tients report  a  great  improvement  in  the  nasal  breathing,  improvement 
in  speech,  and  individuals  who  before  the  treatment  were  able  to  breathe 
through  their  mouths  only  now  breathe  through  their  noses  entirely 
during  the  day  and  night. 

The  appliance,  by  exerting  a  gentle  pressure  on  the  soft  tissues,  car- 
ries the  lateral  halves  of  the  superior  maxillary  bone  laterally  either 
by  direct  mechanical  influence  or  by  development.  The  roof  of  the 
mouth  is  changed,  the  nasal  cavity  increased  in  width,  and  the  deflected 
nasal  septum  is  straightened  because  of  the  increased  room  that  is  made 
for  it.  The  author  does  not  believe  that  the  changes  that  occur  in  all 
of  these  cases  are  the  direct  result  of  mechanical  pressure  but  that  they 
are  the  result  of  mechanical  stimulation  of  the  cells,  which  produces  a 
development  that  has  been  retarded,  and  consequently  the  parts  as- 
sume a  normal  proportion  in  shape  resulting  in  a  normal  development 
of  the  nasal  cavity  following  the  correction  of  treatment  of  malocclu- 
sion. 

Fig.  732  shows  a  model  of  a.  young  patient  in  which  the  only  per- 
manent teeth  present  are  the  first  permanent  molars  with  a  high  nar- 
row arch.  The  patients  suffer  from  mouth-breathing  and  invariably 
show  deflected  nasal  septi  and  nasal  cavities  that  are  below  the  normal 
width.  The  removal  of  adenoids  or  tonsils  that  are  usually  present  does 
not  improve  the  nasal  breathing  because  of  the  deformed  nasal  cavity. 


510  PRACTICAL    ORTHODONTIA 

The  appliance  is  constructed  by  making  bands  upon  the  permanent  mo- 
lars and  the  deciduous  teeth  and  by  adjusting  a  lingual  wire  that  ex- 
tends from  the  canine  to  the  molar.  This  wire  should  be  at  least  a  16- 
gauge  wire  so  as  to  be  of  sufficient  size  to  enable  the  roof  plate  that  is 
to  be  used  to  grasp  the  wire  securely.  After  the  appliance  has  been 
constructed,  or  rather  after  the  band  has  been  made  for  the  molars  and 
canines,  the  lingual  wire  is  put  in  position  as  shown  in  Fig.  732.  The 
roof  plate  is  made  in  the  ordinary  manner  by  waxing  up  with  base 
plate  wax  until  it  is  of  the  desired  thickness.  A  spring  of  some  sort 
is  embedded  in  the  wax,  as  is  shown  in  Fig.  733  and  then  the  plate  is 
vulcanized  in  the  usual  manner. 

This  spring  that  is  embedded  in  the  roof  plate  must  be  made  in  the 
form  of  a  "W,"  as  shown  in  Fig.  733,  in  order  to  give  it  a  greater 
range  of  elasticity  and  to  enable   it  to  be  so   adjusted  as  to  exert   a 


Fig.    732. — Model    of    upper    arch,    showing    anchorage    for    split    plate.      (Richardson.) 

greater  expansion  cither  on  the  canines  or  the  molars.  If  the  spring 
is  made  in  the  form  of  a  "W,"  it  can  be  opened  and  greater  pressure 
exerted  on  the  canines  than  on  the  molars,  or  it  can  be  opened  in  the 
posterior  border  in  such  a  manner  as  to  exert  a  greater  pressure  on 
the  molars  than  on  the  canines.  After  the  plate  is  vulcanized  it  is 
separated  in  the  middle,  as  shown  in  Fig.  734,  and  then  by  opening 
with  springs  the  desired  amount  of  pressure  can  be  produced  upon 
the  canines  or  molars. 

Fig.  735  shows  the  palatal  view  of  the  plate,  which  is  shaped  to  fit 
the  soft  tissue  accurately  so  that  pressure  will  be  brought  to  bear  upon 
the  soft  tissue  and  be  evenly  distributed,  and  thus  produce  no  sore- 
ness. A  groove  in  the  gingival  border  of  the  plate  catches  under  the 
lingual  wire  extending  from  the  canine  to  the  molar  and  thereby  holds 
it  in  position.  The  result  produced  by  this  plate  is  very  gratifying 
because  the  loose  deciduous  molars  are  moved  bodily,  the  roof  of  the 


MALOCCLUSION   AND    NASAL    DEFORMITIES 


511 


mouth  changes  shape,  and  the  nasal  cavity  increases  in  size.  The  re- 
sults from  the  use  of  this  plate  cannot  be  surpassed  by  any  other  form 
of  appliance.  The  treatment  produces  a  change  in  the  shape  of  the 
roof  of  the  mouth  and  in  the  shape  of  the  superior  maxillary  bone 
and  also  produces  a  change  in  the  nasal  cavity.  With  the  use  of  this 
plate  no  provision   is  made  to  exert  pressure  upon  the  anterior  teeth 


Fig.   733  — Roof  plate  with   spring  for  expansion  of  upper  arch.      (  Richardson.) 

if  they  are  protruding,  and  therefore  the  alignment  wire  must  be  used 
to  exert  pressure  on  the  upper  incisors  in  cases  where  some  of  the  upper 
incisors  have  erupted. 

In  younger  patients  where  the  permanenl  incisors  have  not  erupted, 
the  only  kind  of  treatment  necessary  at  this  time  is  the  widening  of 
the  superior  dental  arch,  so  far  as  the  upper  teeth  are  concerned.  Al- 
lowing the  deciduous  teeth  to  assume  such  positions  as  they  will  assume 


Fig.    734. — Oral  view   of   roof  plate  for  expansion   of  arch.      (Richardson.) 


as  the  result  of  change  in  the  atmospheric  and  muscular  pressure,  and 
the  probabilities  are  that  if  sufficient  space  is  made  for  the  upper  cen- 
tral incisors  and  if  the  individual  is  a  normal  breather  at  the  time  they 
erupt,  they  will  take  their  normal  position.  If  it  is  necessary  to  use 
an  intermaxillary  anchorage  to  correct  the  mesio-distal  length  of  the 
arches  with  the  use  of  this  roof  plate,   intermaxillary  hooks  can  be 


512 


PRACTICAL    ORTHODONTIA 


placed  on  the  canine  bands  to  be  attached  to  the  lower  appliance  in  the 
usual  manner.  If  the  patient  is  more  advanced  in  age  and  if  it  is  de- 
sired to  bring  pressure  upon  the  upper  central  incisors  to  correct  a  pro- 
trusion, this  can  be  accomplished  by  soldering  tubes  upon  the  buccal 
surface  of  the  molar  bands  that  will  receive  a  labial  arch  as  illustrated 
in  Fig\  736. 


Fig.    735. — Palatal   view   of   roof  plate,   showing  groove   for   anchorage   on    lingual    wire. 

(Richardson.) 

By  bending  the  labial  arch  gingivally  as  it  leaves  the  buccal  tube,  it 
is  carried  far  to  the  gingival,  and  then  by  using  finger  spurs  pressed 
against  the  protruding  incisors  the  appliance  is  made  very  inconspicuous. 
The  use  of  the  labial  arch  in  no  way  interferes  with  the  action  of  the 
roof  plate.  The  appliance  is  as  inconspicuous  as  any  appliance  that 
can  be  used.     Intermaxillary  anchorage  should  also  be  employed,  by 


Fig.  736. — Labial  arch  with  spur  extensions  which  can  be  used  with  roof  plate  shown  in  Fig.  733. 


having  the  spurs  soldered  on  the  canine  bands  and  by  having  an  inter- 
maxillary hook  attached  on  the  labial  arch.  It  would  be  more  prefer- 
able in  using  intermaxillary  anchorage  to  have  the  spurs  attached  to 
the  canine  band,  because  this  would  give  a  greater  rigidity,  and  the  in- 
termaxillary rubber  would  not  have  a  tendency  to  displace  the  labial 
arch  as  it  would  if  they  were  attached  to  the  labial  arch.    The  combina- 


MALOCCLUSION    AND    NASAL    DEFORMITIES 


513 


tion  of  tin1  labial  arch  with  the  finger  spin-,  as  used  by  Lourie  and  em- 
ployed in  conjunction  with  the  roof  plate  as  used  by  Richardson,  gives  a 
xcvy  ideal  appliance  for  the  treatment  of  patients  who  suffer  from  de- 
formed nasal  cavities,  narrow  arches,  high  palates,  in  which  it  is  desir- 


Fig.    737.— Showing    nasal    septum   bent    from   before   backward. 


ous  to  move  the  teeth  bodily  by  pressure  on  the  alveolar  process,  and 
produce  as  great  a  change  in  the  nasal  cavity  as  it  is  possible  to  pro- 
duce.   In  the  increase  of  width  of  the  dental  arch  and  in  the  increase  of 


514  PRACTICAL   ORTHODONTIA 

space  in  the  nasal  cavity,  deflected  septi  are  corrected  provided  that  the 
deflection  is  from  above  downward. 

Such  deflections  as  are  shown  in  Fig.  737  are  from  before  backward 
and  are  probably  the  result  of  traumatism.  They  are  not  corrected  or 
benefited  to  any  great  extent  by  the  correction  of  malocclusion.  In  be- 
ginning the  treatment  of  a  malocclusion  it  is  very  necessary  to  make 
a  careful  diagnosis  of  the  malocclusion  and  a  careful  examination  of 
the  nasal  cavity  in  order  to  learn  the  exact  condition  of  the  nasal  struc- 
tures. Then  the  appliance  must  be  selected  with  the  idea  of  producing 
as  nearly  as  possible  the  ideal  results.  While  it  is  possible  to  produce  a 
great  change  in  the  nasal  cavity,  care  must  be  taken  not  to  promise  the 
patient  too  much;  and  to  remember  that  only  certain  types  of  deflected 
nasal  septi  can  be  corrrected. 

It  is  our  belief  that  in  the  majority  of  cases  in  which  there  is  a  lack 
of  width  between  the  lateral  walls  of  the  nose,  this  can  be  changed  by 
proper  treatment;  that  the  nasal  cavity  can  be  caused  to  increase  to  its 
proper  size,  and  that  a  great  benefit  can  be  produced  as  far  as  respira- 
tion is  concerned,  provided  that  the  proper  treatment  is  instituted.  In  a 
large  number  of  nasal  deformities  there  is  nothing  that  offers  as  much 
benefit  as  the  proper  correction  of  the  malocclusion  with  the  idea  of 
producing  a  normal  nasal  development. 


IXDEX 

A 

Abnormal  development,  cause  of  malocclusion,  131 

Abnormal  frenum  labium,   134 

Abnormal  relation  of  the  mandible  to  tin-  maxilla?,   70 

Acquired  eauseS  of  malocclusion,  129,  139,  142 

A.denoid  appearance  in  patient,    1!|7 

Adenoids,   location  of,  illustrated,    128 

real  cause  of  mouth-breathing,   129,   1  t!» 
Aderer's  clamp   band,  2  I  1 
Ainsworth  appliance,   189,    199 
Alignment  wire,    187,   195    (See   Expansion  Arch) 

.0225,  use  of,  2.36 
Aluminum-bronze  used  in  making  appliances,  163,  192 
Amalgum  models,  169 
Anatomic  portion   of  mo. lei,   326,   328 

measurement  of.  :;27,  330 
Anchorage : 

linker,  293,  442 

cervical.  297,  298 

classification  of,  table  showing,  281 

compound  reciprocal  intermaxillary,  291,  :ivj,  426 

compound  reciprocal  intramaxillary,  287 

compound  simple  intermaxillary.  291,  2'.'.'; 

compound   simple   intramaxillary,   282 

compound  stationary  intramaxillary,   285 

definition  of.  280 

rxtramaxillary,  280,  297 

facial,  297 

forms  of,  outline  showing,  281 

intermaxillary.  280,  289,  290,  40S,  442,  450,  468,  485,  492,  512 

intramaxillary,  280 

occipital,  297,  298 

occipital  extramaxillary  anchorage,  297 

primary  reciprocal  intermaxillary,   292 

primary  reciprocal  intramaxillary  286 

primary   simple   intermaxillary,  290,   292 

reciprocal,  285,  295 

reenforeed  simple  intramaxillary,  2*2 

simple,  disadvantages  of,  2S3,  292 

simple  compound  reciprocal  intermaxillary,  294 

simple  compound  reciprocal  intramaxillary,  290 

simple   intramaxillary.    281 

.11 .1 


516  INDEX 

simple  primary  intramaxillary,  282 
simple  reciprocal  intramaxillary,  289 
single  reciprocal  intramaxillary,  286 

single  intramaxillary,  282 

single  stationary  intramaxillary,  285 

stationary,  283,  292,  294 

stationary  compound  intermaxillary,  295 

stationary  intermaxillary,  281-294 

stationary  intramaxillary,  281 

stationary  reciprocal  intramaxillary,   289 
Angle's  bracket  band,  243 

classification  of  malocclusion,  49 
compared  with  Lischer's,  50 

expansion  arch,  or  alignment  wire,  189 

jack-screw.  L85 

pin  and  tube  appliance,  235 

ribbon  arch,  244 

traction  screw,  185 
Ankylosis  of  mandible,  facial  deformity  due  to,  110 
Antero-posterior  relation  of  arches,  46 
Appliances,   (See  Regulating  Appliances.) 
Approximal  contact,  normal,  as  force  of  occlusion,  36 

as  force  of  retention,  306,  309 
Arch,  Angle's  ribbon,  244 

method  of  adjusting,  394 
Arches,  malrelation  of,  42-44. 

mesio-distal   relation   of,  -17 

normal  mesio-distal  relation  of,  79 
Arlox  band,  Eogers,  L80 

Ait   portion  of  model,  measurement  of,  '■'•-',  334 
Atmospheric,  pressure,  normal,  as  force  of  occlusion,  28 

as  force  of  retention,  308 
Atrojdiy  of  enamel  organ,  produced  by  syphilis,  117 

*.  B 

Baker  anchorage,  293,   142 
Bands,  160 

bracket,  Angle,  21  I 

clamp,  160,  178 

contoured   ami    noncontoured,    178 

direct  method  of  making,   L63 

indirect    method  of  making,  107 

.Magill,    Kit) 

plain,   160,  177 

1  echnique  for  making,  1  <i."> 

trimming  of,  L64,   1  79 
Hand  forming  pliers,  A  ngle,    I  6  I 
Barnes'  Facial  anchorage,  297 


INDEX  517 

Beauty,  considered  from  orthodontic  standpoint,  81,  92 

Beauty  of  face,  pari  teeth  play  in,  81 

Bilateral  mesioclusion,  or  Class  ill,  cases,  treatment  of,  478 

Bilateral  distoclusion  with   labioversion,  treatment  of,  4.".!) 

Bilateral  distoclusion  with  labioversion  of  upper  anterior  teeth,  11 

Bilateral  distoclusion  with  linguoversion    of  anterior  maxillary   teeth,  4<i7 

Bilateral  distoclusion  with  retruding  anterior  teeth,  or  Class  II,  Division  2,   166 

Bilateral   mesioelusion   with  bunched   mandibular  anterior   teeth,   66 

Bodily  movement   of  teeth,   509 

appliances  for,  23  1 

by  seat    a  a. I   Hat   arch,  2  13 
Bone   ile\  elopment,  500 
Brachyeephalic,  denned,  82 
I  a  ady  's  clamp  band,  244 
Buccal  occlusion,  definition  of,  12 
Buccoversion,  definition  of,  42 
Burrill  lock  for  lingual  arches,  228 

C 

Calipers,   Eawley,   for  measurement  of  lingual  arch,  231 
•  ',-ise's  appliance  for  bodily  movement  of  teeth,  234 

wire  bending  pliers,  268 
Cases,  preliminary  consideration  of/ 318 

t  reatment  of,  374 
Casts,  facial,  valuable  as  records,  342,  343 

full  facial,  technique  for  making,  3.11 

full  facial,  with  dental  insert,  352 

partial  facial,  technique  for  making,  348 

profile,  technique   for  making,  .".44 
Causes  of  malocclusion: 

abnormal  development,    L34 

abnormal   frenum  labium,    134,  305 

abnormal  lip,  137 

acquired,  129,  139,  142 

cell  metabolism,  123 

chicken-pox,  indirect   cause,    117 

children's  diseases,  indirect  cause,   117 

(deft  palate,  134,  305 

congenital,  129,  134,  139 

disuse  of  teeth,  124 

ductless  glands,  diseases  of,  indirect  cause.  127 

early  loss  of  deciduous   teeth,  142 

early  loss  of  permanent  teeth,  14.1 

enlarged   tonsils,   1.1.1,  308 

environments,   121.   126,    129.   13!) 

faulty  development,   121 

family  traits,  indirect   cause,  130 

feeding  of  babies,  improper,  127 

general  or  constitutional,  117 


518  [NDEX 

habits,   156,   187,  305 

harelip,  134 

improper  diet,  124 

improper  restoral  ions,  149 

inherited,   L22,   12'.),  139 

intermarriage  of  races,   1.">1 

local  and  constitutional,  differentiation  of,  128 

loss  of  mesio-distal  diameter  of  teeth,  148 

measles,  indirect  cause,  117 

missing  teeth,   117,   134 

mixing  of   types,   131 

mouth-breathing,    88,    129,    149 

oversized  tongue,   138 

pituitary  bodies,  diseases  of,  indirect  cause,  127 

racial   characteristics,   125 

rickets,  117,  130 

scarlet-fever,    indirect    cause,    117 

sore  teeth,  156 

supernumerary  teeth,  134 

syphilis,  indirect  cause,  117 

tardy  eruption  of  permanent  teeth,  145 

thyroid  glands,  diseases  of,  indirect  cause,   127 

tuberculosis,  121 

undersized  tongue,  138 
Cell  metabolism,  faulty,  as  cause  of  malocclusion,  122 

normal,  as  force  of  occlusion,  28,  123,  127 

as  force  of  retention,  307 
Cephalic  index,  82 
Cervical  anchorage,  297,  298 

Chicken-pox,  indirect  cause   of   malocclusion,   117 
Chin  cap,  297 
Chin,  development  of,  influenced  by  mouth-breathing,  91 

prominent,  with  normal  denture,  91,  94 

receding,  with  normal  denture,  92,  94 
Clamp  for  dental  insert,  355 
Clamp  bands,  160,  178 
Clamp  bands,  adjusting,  178 

Angle,    178 

Arlox,  ISO 

contoured,   and   noncontoured,    179 

Lukens,  180 

with  clamping  device  on  lingual  side,  179 

with  clamping  device  on  buccal  side,   179 
Class  I,  or  neutroclusion,  4.1,   .12 

treatment  of,  374 
Class  I,  mutilated,  or  neutroclusion,  48,  54 

treatment  of,    1 12 
('lass  I,  term  as  used  by  Angle,  is 
Class   I,  Type  1,  4.1,  54 


INDEX  519 

Class  I,  Type  2,  51,  56 

Class  I,  Type  3,  52,  53 

Class  II,  or  distoclusion,  58 

Class  II,  Division  1,  or  bilateral  distoclusion  with  labioversion,  55,  58,  60. 

treatment  of,  139 
•  'lass    II,    Division    1,    Subdivision,    or    unilateral    distoclusion    with    protruding 
teeth,  60 

treatment   of,  465 
Class   11,   Division  2,  or  unilateral  distoclusion  with  protruding  anterior  teeth,  58,  60 

treatment  of,  4fi0 
Class  II,  Division  2,  Subdivision,  or  unilateral  distoclusion  with  retruding  teeth, 
60,  61 

treatment,  478 
Class  II  skull,  79 
Class  III.  or  mesioclusion,  49,  63 
Class  III,  Type  1,  63 
Class  III,  Type  2,  63,  65 
Class  III,  Type  3,  65 

treatment  of,  47s 
Class  HI,  Subdivision,  or  unilateral  mesioclusion,  <>."> 

treatment  of,  492 
''Class  IV,"  incorrect   name   for  cases.   69 
Classification  of  anchorage,  table  showing,  281 

of  Angle's   plan   of  nomenclature,  4!) 

of  Lischer's  plan  of  nomenclature,  50 

of  forces  of  occlusion,  28 

of  malocclusion,  45 
Cleanliness  of  regulating  appliances,    l.",s 
Cleft  palate,  cause  of  malocclusion,  134,  305 
Cleft  palate,  facial  deformity  due  to,  11" 
Coffin  split  plate,  509 
Coffin  split  spring  plate,  2~>.". 
Complex  neutroclusion,  56 

Compound    reciprocal   intermaxillary   anchorage,   291 
Compound  reciprocal  intramaxillary  anchorage,  287 
Compound  simple  intermaxillary  anchorage,  291,  293 
Compound   simple   intramaxillary   anchorage,   282 
Compound  stationary  intramaxillary  anchorage,  285 
Composition  of  appliances,   161 
Compromise   treatment,    112 
Condyle,  relation  of,  to  glenoid  fossa.  7(1 
Congenital  causes  of  malocclusion,  134,  139 
Constitutional  causes  of  malocclusion,  117 
Contouring  appliance,  Case,  I'-"..". 
Cranium,  classification  of,  83 
Crowns,  imperfect,  cause  of  malocclusion,   149 
Cusps,   occlusal,    inclined  planes   of,   20 

relation  of,  to  incline'!  planes,  21,  22 


520  INDEX 

I) 

I  (eciduous  I  eel  li,  early  loss  of,  142 

Dental  insert,  full  facial  east  with,  352 

I  >evelopment,  hick  of,  435 

Diagnostic  aids  in  correction   of  malocclusion,  113 

Distal  occlusion,  definition  of,  42 

Disto-buccal  cusps,  22 

Disto-buccal  inclined  planes,  17,  20 

Distoclusion  cases,  defined,  58 

1  >ist oclusion,  defined,  58 
or  Class  II,  58,  439 

with  labioversiou  of  anterior  teeth,  treatment  of,  4-10,  445 
with  labioversiou  of  upper  incisors,  54,  58,  108 
with  linguoversion  of  upper  anterior  teeth,  56,  58 
use  of  ribbon  arch  in  treatment  of,  244 

Disto-lingual  cusps,  22 

Disto-lingual   inclined    planes,   20 

Distoversion,  definition  of,  43 

Disuse,  cause  of  malocclusion,  124 

Dolichocephalic  index,  defined,  82 

Ductless   glands,   diseases    of,   indirect    cause    of    malocclusion,    ll'i 

Duplicating  orthodontia  models,  336 

Durability  of  regulating  appliances,   Lis 

E 

Efficiency  of  regulating  appliances,   157 
Environments,  cause  of  malocclusion,  125,   129,  139 
Etiology  of  malocclusion,   (See  Causes.) 
Expansion  arch.     (See  also  Regulating  appliances.) 
Ainsworth's  appliance,  189 
Angle's   with    patented   nut,    189 
Angle's  ribbed,  189 

application   of,   195 

attachments  for,   1£2 

combinations  used,    INS 

construction  of,  materials  used   in,   190 

labial,  187,  195 

loop,  labial,  199 

nuts  for,  different  forms  used,   188,  190 

sizes  of,  192 

uses  of,  189 
Extension  spurs  for  lingual  arches,  232 
Extramaxillary  anchorage.     (See  Anchorage.) 
Extramaxillary  retention.      (Set    dl.su   Retention  of  Teeth),  300,  .'117 


Face,  front  and  side  views  necessary,  92 
normal  type  with  normal  occlusion,  91 
principal  features  of,  86 


INDEX  521 


Face-form  and  head-form,  relation  between,  84 
Facial  anchorage,  297 
Facial  casts,  full,  35] 

full,  technique  for  making,  35] 

full,  with  dental  insert,  352 

objections   to   use   of,  358 

partial,  technique  for  making,  348 

showing  normal  occlusion,  88,  90 

valuable  as  records,  342,  343 
Facial  deformities  and   malocclusion,  relation  between,  81 
Facial   deformity  accompanying  mesioclusion,   109 

associated   with  mouth-breathing,  39 
Facial  development  and  malocclusion,  94,  95 

lack  of,  produced  by  neutroclusion,  411 
Facial  index,  82 

Family  traits,  inherited  type  of  malocclusion,  130 
Faulty  development  of  children,  cause  of  malocclusion,   121,  12(5 
Feeding  of  babies,  improper,  cause  of  malocclusion,  127 
Fernald  retainer,  456 

Fillings,  imperfect,  cause  of  malocclusion,  149 
Finger  springs.  224-233,  27u 
Finger-sucking,  cause  of  malocclusion,   156 
Fixed  regulating  appliances,   159,   184 

advantages  of,  160 
Flake  glue,  for  making  duplicate  models,  337 
Force  of  the  inclined  plane,  as  force  of  occlusion,  28,  32 

;is  force  of  retention,   301 
Forces  of  occlusion: 

classification  of,  2S 

definition  of,  2s 

force  of  the  inclined  plane,  32 

harmony  in  size  of  the  arches,  36 

muscular   pressure,   30 

normal  approximal  contact,  36 

normal  atmospheric  pressure,  40 

normal  eell  metabolism,  28 
Forces  of  retention.      (See  Retention  of  Teeth.) 
Frenum  labium,  abnormal,  as  cause  of  malocclusion,  134 

attachment   of,   cause  of  malocclusion,   134 
Full  facial  casts,  technique  for  making,  351 

with  dental  insert,  352 

G 

General  causes  of  malocclusion,  117 

German  silver,  used  in  making  of  appliances,  162,  190 

Glue  impressions,  for  duplicating  models,  :i.",7 

Gnathic  index,  for  studying  protrusion  of  teeth,  S4 

Gold  and  platinum,  used  in  making  of  appliances,  161,  190 

Grass-line  ligature,  181 


522  index 

11 

Eabits  of  childhood,  cause  of  malocclusion,  156,  305 
Harelip,  cause  of  malocclusion,  134 

facial  deformity  due  to,  113 
Harmony  in  size  of  the  arches,  as  force  of  occlusion,  28  :!<> 

as  force  of  retention,  302 
Hawley  calipers  for  measurement  of  lingual  arch,  231 
Head-form  and  face-form,  relation  between,  84 
Headgear  and   chin   retractor,  illustrated,  297 
Hooks,  technique  of  making,  lil.'j 
Hutchinson  teeth,  117 

I 
Impacted  teeth,  treatment  of,  437 
Impressions : 

duplicating  orthodontia  models,  336 

facial  casts,  342 

methods  of  taking,  318 

modeling  compound,  for  study  models,  335 

modeling  compound,  not  satisfactory,  318 

plaster  used  in  taking  of,  318,  321 

removing  from  mouth,  322 

trays  for  holding  plaster,  319 

uniting,  322 

varnishing,  323 
Improper  restorations,  cause  of  malocclusion,  14!) 
Inclined  planes  of  teeth,  how  named,  17 

diagram  showing,  20,  21 

forces  of,  32,  182 

outline  showing  occlusion  of,  23 
Inconspicuousness  of  regulating  appliance,   159 
Infra-occlusion,  definition  of,  42 
I  nt'ra version,  definition  of,  42 
Inharmony  in  size  of  arches,  37,  3(>."» 
Inherited  causes  of  malocclusion,  129,  139 

family  traits,  130 

intermarriage  of   races,    l.'ll 

mixing  of  types,  131 
Inlays,  imperfect,  cause  of  malocclusion,  149 
Intermaxillary  anchorage.      (See  Anchorage.) 
Intermaxillary  retention.      (See  Retention  of  Teeth.) 
Intermaxillary  hook,  193 

Intramaxillary  anchorage.     (See  Anchorage.) 
Intramaxillary  retention.      (See  Retention  of  Teeth.) 
Iridio-platinum,  used  in  making  regulating  appliances,  161,  li>l 


TXDEX 

J 

Jack-screw : 

advantages  and  disadvantages  in   use  of,   185 

Angle's,  illustrated,  185 

attachments  of,  185 

attached  to  band,  287 

combinations  of,  1 85 

traction  screw,  modification  of,  1 85 
Jackson's  all-metal  removable  appliances,  254 

crib  appliance,  204 

partial  clasp  metal,  257 

removable-fixed  appliances,  l!.j0 

system  of  removable  appliances,  254 
.1  umping-the-1  dte,  4-12 


Key  to  occlusion,  defined  by  Angle,   4i 


Labial  and  lingual  arch  in  combination,  with  spring  extensions,  24S 
Labial  arch,  in  combination  with  finger  spur,  462 

used  with  lingual  arch,  247 
Labial  expansion  arch,  187,  195 
Labial  occlusion,  definition  of,  42 
Labial  wire  with  spur  extensions,  462 
Labioversion,  definition  of,  4l! 
Lap  bands,  163,  165 

Large  tongue,  congenital  cause  of  malocclusion,  138 
Ligature  jack,  Lourie,  185 
Ligatures,  kinds  of,  1.S1 

rubber,  182 

silk  or  grass-line,  181 

wire,  1S2 
Line  of  occlusion,  definition  of,  28 

Lingual  and  labial  arch  in  combination,  with  extension  spring,  217 
Lingual  arch,  calipers  for  measurement  of,  23] 

cases  of  mesioclusion  treated  with,  492 

fixed,  205 

locking  devices  for  holding  spurs,  228 

Lourie 's  technique,  205 

Mershon's  technique,  226-230 

removal  4e,  220 

styles  of  application,  207 

use  of,  in  cases  of  bilateral  distoelusion,  476 

used  with  labial  arch,  245 
Lingual  occlusion,  definition  of,    1.". 
Linguoversion,  definition  of,  43 
Linguo-torsi-occlusion ,  43 


524  INDEX 

Lip,  abnormal,  cause  of  malocclusion,   L37 

Lip-habits  and  malocclusion,  88 

Lip-sucking  and  lip-biting,  causes  of  malocclusion,   L56 

Lips,  abnormal  function  of,  due  to  malposition  of  incisors,  !»i 

development  of,  and  malocclusion,  98,  103 
Lischer's  classification  of  malocclusion,  42,  50 

compared  with  Angle's,  50 
Lock  for  use  with  perpendicular  tube  on  molar  band,  22S 
Lourie's  ligature  jack,  185 
Lourie's  spur-forming  pliers,  190,  191 
Lourie  's  technique  for  lingual  arches,  205 
Loop  appliance,  application  in  neutroclusion,  202 

combinations  of,  203 

with  pins  and  tubes,  201 

with  threaded  arch,   204 
Loop  labial  alignment  wire,  199 
Lukens'  clamp  band,  180 

M 

Macromandibular  development,  73,  7G 

Macromaxillary  development,  76 

Magill  band,  160 

Malformations  of  the  jaws  and  their  processes,  70 

result  of  malocclusion,  70 
.Malocclusion  and  facial  deformities,  relation  between,  81 
Malocclusion  and  nasal  deformities,    199 
Malocclusion,  classification  of,  44 

definition  of,  17,  42 

diagram  showing,  43 

division  into  groups,  42,  47,  49 

etiology  of,  117.     (See  Causes.) 

Lischer's  classification,   12,  50 
compared  with  Angle's,  50 

positions  of,  42 

produces  abnormal  jaw  and  process,  81 
Malocclusion,  facial  development  in,  95 
Malposition  of  the  mandible,  42 

deformity  due  to,  110 

facial  deformity  in,  106 
Malpositions  of  the  individual  teeth,  42 
Malrelation  of  the  arches,   12,  45 
Mandible,  abnormal  relation  to  maxillae,  69 

ankylosis  of,  110,  113 

curvature,  76 

malposition  of,  69 

facial  deformities  due  to  maldevelopment  of,  110 

facial  deformities  due  to  malposition  of,  110 
Mandibular  anteversion,  defined,  71 
Mandibular  retroversion,  defined,  71 


INDEX  •)_•) 


Materials  used  in  making'  bands,  160 

Maxilla,  superior,  illustrated,  29 

Maxillary  bones,  152 

Measles  indirect  cause  of  malocclusion,  117 

Measuring  plaster  models,  332 

Mechanical  forces  of  retention.      (See  Retention  of  Teeth.) 

Mershon  \s  technique  for  lingual  arches,  205 

Mesial  occlusion,  definition  of,   12.  43 

Mesiodmccal  cusps,  22 

Mesio-buccal  inclined  planes,  21 

Mesioelusion  cases,  defined,  (i.'l 

Mesioelusion,  defined,  •'>■"• 

facial   deformity  in,    109,    112 

or  Class  III,  63,  68 
treatment  of.    17  s- 

use  of  ribbon  arch  in  treatment   of,  I'll 
Mesioelusion  with  macromandibular  development,  112 
Mesio-distal  diameter  of  teeth,  loss  of,  118 
Mesio-distal  relation  of  arches,   17 
Mr  sio-labio-torsi-infra-occlusion,  41 
Mi  sio-labio-torsi-infraversion,  44 
Mesio-torsi-infraversion,  definition,  4'.', 
Mesiodingual  cusps,  22 
Mesio-lingual  inclined  planes.  21 
Mesio-torsi-infra-occlusion,  43 
Mesioversion,  definition  of,  42 
Mesocephalic  index,  defined.  82 
Mesognathic  index,  defined,  83 
Metal  models,  material  used  for,  163 
Micromandibular  development,  75,  7  7 
Micromaxillary  development,  76 

Mixing  of  types,  inherited  cause  of  malocclusion,  131 
Missing  teeth,  cause  of  malocclusion,  117,  134 
Models,  amalgam,  169 

duplicating,  method  of,  336 

instruments  for  trimming,  .",27.  :i2^ 

measuring,  method  of,  329 

metal,  material  for,  163 

pouring,  324 

separating,  326 

study,  made  from  modeling  compound,  335 

trimming,  327 
Modeling  compound  impressions,  318 
Modeling  compound  to  study  models,  335 
Molars,  buccal  and  lingual  relation  of,  20 
Mouth,  roof  of,  at  birth,  152 
Mouthdjreathers,  facial  deformities  in.  96 
Moutlvbreathing,  499 


520  ENDEX 

Mouth-breathing,  cause  of  malocclusion,  129,  1 4 i » ,  441 

facial  deformity  associated  with,  39,  149,  155 
•  influence  on  development  of  nose,  89 

influence  on  mouth,  88 

typical  case  of,  39 

photographs,  value  of,  341 
Mouth,  development  of,  influenced  by  mouth-breathing,  88 

roof  of,  505 
Muscular  pressure,  as  force  of  occlusion,  28,  30 

as  force  of  retention,  305 

N 

Nasal  and  oral  cavities,  relation  of,  152 
Nasal  cavity,  embryonic  development  of,  500 

posterior  view  of,  38 
Nasal  deformities  and  malocclusion,  499 
Nasal  septum,  development  of,  503 

Naso-labial  sulcus,  development  of,  influenced  by  mouth-breathing    88 
Nasopharynx,  illustrated,  128,  151 

Natural  forces  of  retention.      (See  Retention  of  Teeth.) 
Neutroclusion,  complex  cases  of,  52,  56 

complicated  by  infraversion  of  anterior  teeth,   102 

complicated  by  labioversion    of   upper  and    lower  anterior  teeth,   106 

complicated  by  linguoversion  of  upper  incisors,  W 

definition  of,  52 

facial  deformities  in,  96 

mutilated,  case  of,  51,  54 

with  bunched  anterior  teeth,  45,  51,  54 

with  labioversion  of  upper  incisors,  52,  56 

with  linguoversion  of  upper  anterior  teeth,  53,  56 
Neutroclusion  cases,  denned,  52 

diagnostic  aids  in,  113 
Nickel  silver,  used  in  making  of  appliances,    Hi!',   190 
Nomenclature,  Angle's,  49 

Lischer  's,  50 
Non-corrosive  material,  used  in  making  of  appliances,  161 
Normal  approximal  contact,  as  force  of  occlusion,  28,  36 

as  force  of  retention,  306 
Normal  atmospheric  pressure,  as  force  of  occlusion,  2s,  39 

as  force  of  retention,  308 
Normal  cell  metabolism,  as  force  of  occlusion,  28,  12.1,  127 

as  force  of  retention,  307 
Normal  muscular  pressure,  as  force  of  occlusion,  28,   30 

as  force  of  retention,  305 
Normal  occlusion,  definition   of,   17 

skulls  illustrating,  18,  19 

face  showing,  91 

facial  cast  showing,  89 
Normal  skull,  SO 


INDEX 

Nose-breathing,  effect  on  malocclusion,  40 

Nose,  development  of,  influenced  by  mouth-breathing,  89 

O 
Occipital  anchorage,  297,  298 
Occlusion : 

buccal,  43 

definition,  17 

distal,  4.". 

forces  of,  28 

classification,  28 
definition,  28 

infra-,  43 

labial,  4.'! 

Line  of,  30 

lingual,   43 

mesial,  42 

mesio-labio-torsi-infra-,    1  I 

mesio-torsi-infra-,  43 

normal,  17 

of  inclined  planes,  17,  23 

supra-,  43 

torsi-,  43 

torsi-mesial,  4.". 
Oliver's  facial  casts,  342-357 
Orthodontia,  definition  of,  17 
Orthognathic  index,  defined,  84 
Ottolengui's  modification  of  split  plate,  509 
Oversized  tongue,  congenital  cause  of  malocclusion,  138 


Palate,  hard  and  soft,  illustrated,   128 

Partial  clasps,  used  in  Jackson's  removable  appliances,  2(30 

Partial  facial  cast,  technique  for  making,  348 

Peridental  membrane,  507 

Permanent  teeth,  early  loss  of,  14.5 

tardy  eruption  of,   145 
Perversion,  definition   of,  43 
Photographs,  valuable  as  records,  340 
Pin  and  tube  appliance,  Angle,  235 

Pin  and  tube  appliance,  in  mesioclusion,  or  ('lass  III  cases,  492 
Pin  and  tube,  used  with  .0225  wire,  236 
Pinch  bands,  163 

Pituitary  body,  diseases  of,  indirect  cause  of  malocclusion,  127 
Plane  and  spur  retention,  315 
Plain  bands,  160,  177 


527 


528  INDEX 

Plaster  bowl,  321 

plane,  310 

trays,  319 

used  for  taking  impression,  319 
Plaster  model  for  indirect  band-making,  169 
Pliers,  Angle's  band-forming,  161 

Angle's  soldering,  164 

Angle's  wire-stretching,  206 

Bognc,  207 

How,  modified,  207 

Lourie's  spur,  191 

Lourie 's  wire-stretching,   206 

Mershon's  band-stretching,  172 

sharp-nosed,  236 

stretching,    206 

wire-bending,  Case,  268 
Position  of  malocclusion,  42 
Positions  of  teeth,  normal,  43 
Pouring  plaster  models,  324 
Profile  casts,  technique  for  making,  344 

evolution  of,  82,  84 

in  infancy,  82 

in  maturity,  82 

in  senility,  82 
Prognathic  index,  defined,  83 

R 
Racial  characteristics,   83 

as  cause  of  malocclusion,  125 
Racial  types,  European,  86 

Radiography  in  orthodontia.      (See  X-ray   in  Orthodontia.) 
Reciprocal  anchorage,  285,  295 
Regulating  appliances: 
application  of,  195 
composition   of,   161 
definition  of,  157,  253 
fixed,  159,  184,  253 
making  of,  technique,  160 
materials  used  in  making,  160 
principles  of,  157 
removable,  159,  253 

advantages  of,  276-278 

all-metal  appliances,  256 

body  wires,  264 

Coffin  split  spring  plate,  254 

disadvantages  in  use  of,  256 

early  types,  255 

finger  springs,  267 

instruments  required  for  making,  256 

Jackson's   system,   255 


IXDEX 

lower  appliance,  construction   of,  272 

materials  used,  258 

part  ial  clasps,  262 

plaster  models,  260 

removable-fixed  type,  256 

spring  clasps,  26  1 

technique  of  construction,  260-265 
requirements  of,  157 

ant  i-rpMs,  158 

cleanliness,  158 

durability,  158 

efficiency,   l-~>7 

inconspicuousness,  159 

simplicity,   15S 
Removable  appliances,  159,  253,  256,  260 

advantages  ar.d  disadvantages  of,   160,  255 
Removable  retaining  appliances,  Beaser,  458 

Fernald,  456 
Removable-fixed  appliances  of  Jackson,  257 
Retention,  study  models,  valuable  in,  336 
Retention  of  teeth: 
definition  of,  299 
mechanical  forces,  310 

active,  20<> 

active   primary    intermaxillary    retention,   314 

active    reciprocal   intermaxillary    retention,    316 

compound    active    reciprocal    intermaxillary    retention,    31(5 

compound  reciprocal  intramaxillary  retention,  312 

compound  reciprocal  passive  intramaxillary  retention,  313,  317 

extramaxillary  retention,  300,  317 

intermaxillary   retention,   300,   310,   313 

intramaxillary  retention,  300 

passive  retention,  299-310 

passive  reciprocal  simple  intermaxillary  retention,  314 

passive    reciprocal    stationary    intermaxillary    retention,    31G 

plane  and  spur  retention,  315 

primary  passive  intermaxillary  retention,  313 

reciprocal  intermaxillary  retention,  314 

reciprocal  intramaxillary  retention,  311 

simple  compound  intramaxillary  retention,  310 

simple  passive  intramaxillary  retention,  310 

stationary   intramaxillary   retention,   311 
natural  force,  300 

force   of   the   inclined   plane,   301 

harmony  in  the  size  of  the  arches,  302 

normal  approximal  contact,  306 

normal  atmospheric  pressure,  SOS 

normal  cell  metabolism,  307 

normal  muscular  pressure,  305 

summary  of,  308 


529 


530  INDEX 

Ribbon   arch,  Angle,  24.'! 

Richardson's  modification  of  split  plate,  511 

on  Lmpaeted  molars,  438 
Rickets,   cause   of   malocclusion,   117,   142 
Robinson's  .922  alignment   wire  appliance,  238 
Robinson's  appliance,  192,  238 

Roof  plate,  in  combination  with  labial  arch  and  linger  spur,  516 
Roof  plate  with  spring  for  expansion  of  upper  arch,  .">12 
Rubber  ligatures,  181 

S 

Separating   plaster  models,  326 

Scarlet  fever,   indirect  cause   of  malocclusion,   117 

Sheath-hook,  193 

Silk   ligatures,    181 

Simplicity  of  regulating  appliances,  158 

Sinuses,  posterior  view  of,  38 

Soft-soldering,  174,  192 

Soldering  pliers,  Angle,  1(54 

Soldering  technique,   164-175 

Solder,  in  wire  form,  164 

Sore  teeth,  cause  of  malocclusion,  156 

Split  spring  plate  of  Coffin,  .109 

modifications  of,  510 
Spring  clasps,  for  Jackson's  removable  appliances,  264 
Spur  extensions,  labial  wire  with,  4<i2 

Spur,  triangular,  and  tube  used  with  lingual  wire,  Fernald,  458 
Spurs : 

attachment   of,   194 

extension,  for  lingual   arches,   232 

extensions  for  labial  and  lingual  arches,  247 

for  bodily  movement  of  teeth,  194,  481 

half-loop,  193 

half-round,   229 

locking  devices  for  holding,  227 

making  of,  174 

on  lingual  arches,  228 

soft  solder,  forms  of,  illustrated,   193 

soldering  to  bands,  173,  174 

to  depress   canines,  194 

to  prevent  ligature  from  slipping,  184,  192 

tubes  used  as,  193 
Spur-forming  pliers,  191 
Stationary  anchorage,  283,  291,  298,  403 
Study  models,  made  from  modeling  compound,  336 
Supernumerary    teeth,   congenital    cause   of   malocclusion,    1.".4 
Supra-oeclusion,  43 
Supraversion,  definition  of,  43, 


INDEX  531 

Sut me,  opening  of,  aid  to  treatment,  508 
Syphilis,  indirect  cause  of  malocclusion,  117 

T 

Tardy   eruption   of  permanent   teeth,   145 

radiograph  showing,  369 
Thyroid  diseases,  indirect  cause  of  malocclusion,  127 
Thumb-sucking,  cause   of  malocclusion,   156 
Tonsils,  enlarged,  effects  of,  155,  308 
Torsi-mesial  occlusion,  43 
Torsi-occlusion,  43 
Torsiversion,  definition  of,  43 
Traction  screw,  use  of,  with  stationary  anchorage.  284 

Angle's  illustrated,  185 
Transversion,  definition  of,  43 
Trays  for  taking  plaster  impression,  319 
Treatment,  study  models  valuable  in,  336 
Treatment  of  cases: 

of  bilateral  distoclusion  with  labioversion,  or  Class  II,  Division  1,  439 

of   bilateral  distoclusion  with  retruding  anterior  teeth,  or  Class  II,  Division 
2,  Subdivisions,  466 

of  mesioclusion,  or  Class  III,  478 

of  neutroclusion,  or  Class  I,  374 

of  neutroclusion,  or  Class  I,  mutilated,  412 

of  unilateral  distoclusion  with  protruding  anterior  teeth,  or  Class  II,  Division 
1,   Subdivision,  465 

of  unilateral  distoclusion  with    retruding  teeth,  or  Class  II,  Division  2,  Sub- 
division, 478 

of  unilateral  mesioclusion,  or  Class  III,  Subdivision,  492 
Trimming  plaster  models,  327 
Tube,  square,  devised  by  Kemple,  405 
Tube-hook,  193 
Tuberculosis,  indirect  cause  of  malocclusion,  121 

U 

Undersized  tongue,  congenital  cause  of  malocclusion,   138 
Unilateral    distoclusion,    defined,    69 

with   bunching   upper  anterior  teeth,   62 

with   labioversion   of  upper  anterior  teeth,  50 

with   linguoversion  of  upper  incisors,  <il 
Unilateral  mesioclusion,  defined,  69 

or  Class  III,  subdivision,  treatment  of,  492 

W 

Wax  models,  used  as  diagnostic  aids,  114,  115 
Wire  bending  in  making  appliances,  265 
Wire-bending  pliers,  Case,  2<i7 


532  INDEX 

Wire   ligatures,  182 

Wire  stretchers,  Angle's,  206,  207 

Lourie's  206,  207 
Wire-stretching  technique,  208,  210,  214,  218,  220 

X 
X-ray  in  orthodontia: 

extra-oral  method,  most  satisfactory,  360 
indications  for  use  of,  366 

intraoral  method  not  satisfactory,  360 
seat  ing  the  patient,  36] 
technique,  360 
value  of,  359 

Y 
Young-Angle  lock  for  lingual  arches,  227 


COLUMBIA  UNIVERSITY  LIBRARY 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

1 

C28(2J8)M100 

RK521 
Dewey 
Practical  orthodontia. 


D51 
1919 


3C 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsl.stx) 

RK521D51  1919  C.1 

Practical  orthodontia 


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